COLUMBIA  LIBRARIES  OI-I-&I  1 1 

HEALTH  SCIENCES  STANDARD 


HX641 39581 
RC941  .In4  1894     Diseases  of  the  ches 


Hjii^i 

(^ElOS«GQil»  M.D. 

RC74/ 


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Columbia  ZHnitier^itp 

intijeCttpofltogork 

College  of  $f)pgtctans  anb  burgeon* 
Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofchesttOOinga 


DISEASES 


Chest,  Throat 


NASAL  CAVITIES 


INCLUDING 


Physical  Diagnosis  and  Diseases  of  the  Lungs,   Heart,   and  Aorta, 

Laryngology  and  Diseases  of  the  Pharynx,   Larynx, 

Nose,  Thyroid  Gland,  and  (Esophagus; 


E.  Fletcher  Ingals,  a.m.,  m.d. 

professor  of  laryngology  and   practice  of  medicine,  rush   medical  college;  professor  of 
diseases  of  the  throat  and  chest,  northwestern  university  woman's  medical  school, 
professor  of  laryngology  and  rhinology,  chicago  polyclinic;  laryngologist  to  the 
st.  Joseph's  hospital  and  to  the  Presbyterian  hospital,  etc.;  fellow  of  the 
american    laryngological    association   and    american    climatological 
association  ;  member  of  the  american  medical  association,  illi- 
nois   state    medical    society,    chicago    medical    society, 
chicago    pathological    society,    etc.,    etc. 


THIRD    EDITION,   REVISED. 


WITH    TWO    HUNDRED    AND    FORTY    ILLUSTRATIONS. 


NEW  YORK 
WILLIAM    WOOD    &   COMPANY 

1894 


Copyrighted,  1894, 
By  WILLIAM   WOOD  &  COMPANY 


TO   MY   PRECEPTOR, 

EPHRAIM  INGALS,   M.D., 

EMERITUS  PROFESSOR    OF   MATERIA   MEDICA    AND   MEDICAL 

JURISPRUDENCE    IN    RUSH   MEDICAL  COLLEGE,   TO 

WHOSE   ENCOURAGEMENT  AND  WISE 

COUNSEL   I  AM   GREATLY 

INDEBTED, 

Gbts  3Boofc  is  affectionately  Beoicateo 

BY  THE  AUTHOR. 


PREFACE   TO   THE   THIRD   EDITION. 


rpiHIS  is  not  meant  for  an  encyclopedic  work,  but  is  intended  to  pre- 
sent in  convenient  form  the  known  facts  relating  to  diseases  of  the 
respiratory  tract  and  circulatory  organs,  and  I  have  brought  their  con- 
sideration under  one  cover  because  the  parts  are  so  closely  related  that 
when  one  is  diseased  it  is  generally  necessary  to  interrogate  the  others 
before  a  correct  diagnosis  or  proper  plan  of  treatment  can  be  reached. 

I  have  not  discussed  questionable  theories,  and  have  not  referred  to 
methods  of  treatment  which  do  not  strongly  commend  themselves  to  my 
judgment. 

The  favor  with  which  the  preceding  edition  of  this  work  has  been 
received  leads  me  to  believe  that  I  have  succeeded  in  my  efforts,  not  only 
to  aid  laryngologists  in  their  daily  work  but  also  to  place  these  subjects 
clearly  before  students  and  a  large  class  of  general  practitioners  who  of 
necessity  must  be  prepared  to  meet  any  emergency. 

As  it  is  but  little  over  a  year  since  the  second  edition  was  published 
no  great  alteration  in  the  text  has  been  necessary,  but  several  minor 
changes  have  been  made,  and  a  few  pages  have  been  added  to  keep  abreast 
of  our  advancing  knowledge  on  these  subjects.  E.  F.  I. 

34-36  Washington  St.,  Chicago. 


PKEFACE   TO   THE   SECOKD   EDITION. 


TN  the  first  edition  of  this  work,  the  consideration  of  the  diseases  of 
the  respiratory  and  circulatory  systems  was  restricted  to  such  a 
presentation  of  the  diagnosis  and  treatment  as  I  had  formerly  made  in 
my  lectures  to  classes  of  students.  With  the  purpose  of  completing  the 
work  and  increasing  the  value  of  this  edition  to  both  students  and  prac- 
titioners, there  have  been  added  the  subjects  of  Etiology,  Pathology, 
Symptomatology,  and  Prognosis  of  the  diseases  to  which  these  organs 
are  liable. 

The  chapters  devoted  to  physical  diagnosis  have  been  but  little 
changed.  Those  treating  of  diseases  of  the  lungs  and  heart  have  been 
amplified  and  modified  to  correspond  with  the  present  advanced  line  of 
our  knowledge  on  these  subjects,  and  those  relating  to  diseases  of  the 
throat  and  nasal  cavities  have  been  entirely  rewritten.  I  have  endeav- 
ored to  include  all  diseases  of  the  chest,  throat,  and  nasal  passages,  as 
well  as  the  more  important  affections  of  the  oesophagus  and  thyroid 
gland,  and  to  give  to  each  the  consideration  which  its  frequency  and 
importance  demand.  I  have  carefully  consulted  the  extensive  litera- 
ture of  these  topics  but  have  made  no  attempt  to  collate  the  various 
theories  and  methods  suggested  by  different  authors.  I  have  limited 
the  argument  to  that  which  personal  knowledge  of  the  diseases  and  of 
writers,  commends  to  my  own  judgment;  and  I  have  generally  confined 
my  recommendations  for  treatment  to  those  methods  which  have  proved 
most  efficacious  in  my  own  practice.  The  substance  of  the  writings  of 
an  individual  soon  becomes  merged  in  general  literature  which  makes  it 
impossible  for  me  to  give  personal  credit  as  I  would  like,  to  all  whose 
labors  have  enriched  this  field,  but  to  all  such  I  gladly  acknowledge  my 


x  PREFACE  TO   THE  SECOND  EDITION. 

indebtedness.  I  am  indebted  to  Drs.  Ephraim  Ingals,  Walter  S.  Haines, 
J.  Edwin  Rhodes,  and  Norman  Bridge  for  aid  in  proof-reading,  and  to 
Dr.  Arthur  M.  Corwin  and  James  H.  Blodgett  for  assistance  in  proof- 
reading and  revision  of  copy,  as  well  as  to  Dr.  M.  A.  Olsen  for  the 

index. 

E.  F.  I. 

34-36  Washington  St.,  Chicago, 
September,  1892. 


PEEFAOE   TO   FIRST   EDITION. 


These  lectures  are  designed  to  present  a  complete  exposition  of  the 
subject  of  Physical  Diagnosis  so  far  as  it  relates  to  diseases  of  the  Chest, 
Throat,  and  Nasal  Passages;  to  give  the  essential  symptoms  of  each 
disease;  to  point  out  the  symptoms  and  signs  which  are  of  most  value 
in  a  differential  diagnosis;  and  to  outline  briefly  the  proper  treatment 
for  the  various  affections.  The  anatomical  characteristics  and  the 
causes  of  these  diseases  have  been  pointed  out  wherever  they  are  of 
special  value  in  enabling  the  reader  to  understand  the  physical  signs, 
or  to  properly  apply  remedial  measures.  When  these  lectures  were  de- 
livered, nothing  was  said  about  treatment,  but  in  order  to  enhance  the 
value  of  this  work  to  both  physician  and  student,  I  have  appended  to 
the  consideration  of  the  diagnosis  of  each  disease  an  outline  of  the 
treatment  which  I  have  found  most  satisfactory.  In  so  doing,  I  have 
not  even  mentioned  many  methods  of  treatment  of  more  or  less  value 
which  have  been  recommended  by  other  physicians. 

In  the  preparation  of  these  lectures  I  have  availed  myself  of  every 
source  of  information  at  my  command,  and  I  hope  that  little  has  been 
overlooked  which  would  be  of  value  to  the  student  or  practitioner. 
The  study  of  this  subject  for  several  years,  in  connection  with  my  lec- 
tures, and  a  large  personal  experience  with  these  affections  have  enabled 
me  to  discriminate  as  to  the  relative  importance  of  different  signs  and 
to  detect  numerous  exceptions  to  the  general  rules.  These  exceptions, 
some  of  which  are  extremely  rare,  are  of  little  importance  to  the  general 
practitioner,  and  the  study  of  them  is  a  positive  injury  to  the  student 
unless  their  true  significance  is  understood.  Matter  relating  to  them 
has,  therefore,  been  set  in  small  type,  so  that  it  may  be  omitted  until 
the  student  has  become  thoroughly  familiar  with  the  facts  that  are 
essential. 

The  nature  of  these  lectures,  which  contain  information  gathered 
from  many  different  sources  by  study  and  by  personal  observation,  and 


xii  PREFACE  TO  FIRST  EDITION. 

the  fact  that  much  of  which  they  treat  has  long  since  become  public 
property,  renders  it  impossible  for  me  in  every  instance  to  give  the 
credit  to  individual  authors  which  I  desire,  but  I  freely  acknowledge 
my  indebtedness  to  all  who  have  preceded  me  in  this  field.  I  am  in- 
debted to  the  courtesy  of  Doctors  J.  Solis  Cohen,  of  Philadelphia,  and 
Lennox  Browne  and  Morell  Mackenzie,  of  London,  for  permission  to 
use  some  of  the  cuts  which  illustrate  their  works.  I  take  special 
pleasure  in  expressing  my  obligation  to  my  clinical  assistants,  Doctors 
Philip  Leach,  W.  H.  Taylor,  and  J.  T.  Eggers,  for  valuable  aid  in  the 
revision  of  my  notes. 

Messrs.  Sharp  &  Smith,  of  this  city,  have  kindly  furnished  electro- 
types for  the  illustrations  of  instruments. 

E.  F.  I. 


CONTENTS. 


PAGE 

Preface, vii 

List  of  illustrations,  ..........         xxiii 

DISEASES    OF   THE   CHEST. 

CHAPTER    I. 

Physical  diagnosis, 3 

Divisions  of  the  chest 3 

Methods  of  examination, 9 

Inspection, .         .         .         „         ,  9 

Palpation, .  14 

Mensuration, 16 

Succussion, .  20 

CHAPTER  II. 

Physical  diagnosis,  continued,  .........     21 

Percussion, 21 

In  health, °         .....     21 

In  disease, .28 

The  Plessigraph, 31 

Auscultatory  percussion, 32 

CHAPTER   III. 

Physical  diagnosis,  continued,  . 34 

Auscultation,      ............     34 

In  health, 39 

In  disease,     .         .         .         .         .         .         .        .        .  .        .41 

CHAPTER  IV. 

Physical  diagnosis,  continued, 48 

Adventitious  sounds, .48 

Vocal  sounds,       . 54 

CHAPTER  V. 

Pulmonary  diseases, .         .         .        .        .  60 

Pleurisy, 60 

Acute  pleurisy, 61 

Subacute  pleurisy 72 


xiv  CONTENTS. 

CHAPTER  VI. 

PAGE 

Pulmonary  diseases,  continued 76 

Chronic  pleurisy  or  empyema 76 

Peculiar  local  forms  of  pleurisy, 82 

Hydrothorax 84 

Pneumothorax, 84 

Pneumo-hydrothorax, 85 

CHAPTER  VII. 

Pulmonary  diseases,  continued, 89 

Bronchitis, 89 

Acute  and  subacute  bronchitis, 89 

Chronic  bronchitis, 90 

Capillary  bronchitis, 95 

Plastic  bronchitis 99 

Dilatation  of  the  bronchial  tubes 100 

Asthma, 102 

Pulmonary  emphysema, 107 

CHAPTER  VIII. 

Pulmonary  diseases,  continued.        .........  113 

Pneumonia, 113 

Lobar  pneumonia,         . 113 

Lobular  pneumonia.      ..........  123 

Peculiar  forms  of  pneumonia,      ........  128 

Abscess  of  the  lungs,  ...........  129 

CHAPTER    IX. 

Pulmonary  diseases,  continued,        . 132 

Pulmonary  hyperaemia,       ..........   132 

Brown  induration, 134 

Pulmonary  hemorrhage, 134 

Pulmonary  apoplexy. 137 

Pulmonary  thrombosis  and  embolism, 138 

Pulmonary  collapse,    ...........   139 

Pulmonary  oedema,     ...........   142 

Pulmonary  gangrene,  .         .         .         .         .         .         .         .         .         .144 

Pulmonary  cancer.       ...........   146 

Pulmonary  tumors,     . 148 

Hydatid  cysts  of  the  lungs, 148 

Distoma  pulmonale, 150 

Syphilitic  diseases  of  the  lungs. •    .   151 

Enlarged  bronchial  glands,         .........   152 

Pertussis  or  av hooping-cough,    . .   153 

CHAPTER  X. 

Pulmonary  diseases,  continued, 156 

Pulmonary  phthisis,   ...........  156 

Pulmonary  tuberculosis, .156 

Acute  miliary  tuberculosis,  ........    165 

Fibroid  phthisis, 167 


CONTENTS.  xv 

CHAPTER    XI. 

PAGE 

The  heart, 177 

Anatomy  and  physiology  of  the  heart, 177 

Physiological  action  of  the  heart, 180 

Physical  examination  of  the  heart,    ........  183 

Cause  of  the  heart  sounds, 190 

Modification  of  the  heart  sounds  by  disease, 191 

CHAPTER  XII. 

The  heart,  continued, 195 

Abnormal  heart  sounds,  cardiac  murmurs,  .         .         .         .         .195 

Anomalous  heart  sounds .         .         .         .  205 

Subclavian  murmurs, 206 

Venous  signs,       ..........  .  206 

The  sph3Tgmograph, „  208 

CHAPTER  XIII. 

Cardiac  diseases, 212 

Pericarditis, 212 

Pneumo-hydropericardium, 218 

Hydropericardium,     . 218 

Endocarditis, .  .         .   219 

Acute  endocarditis,      .         .         .         .         .         .         .         .         .         .  219 

Ulcerative  endocarditis, .  222 

Chronic  endocarditis,  valvular  disease  of  the  heart,  .         .         .  223 

Myocarditis,         . .         .         .  231 

CHAPTER   XIV. 

Cardiac  diseases,  continued,     ..........  234 

Simple  cardiac  hypertrophy, 234 

Hypertrophy  and  dilatation  of  the  heart, 236 

Dilatation  of  the  heart,       . 239 

Atrophy  of  the  heart, 242 

Fatty  heart, 242 

Aneurism  of  the  heart,         ..........  245 

Rupture  of  the  heart, 245 

Syphilitic  disease  of  the  heart, 245 

Tumors  of  the  heart, 246 

Morbus  cseruleus, 246 

Neurotic  or  functional  disease  of  the  heart,       .         .         .         .  -       .         .  247 
Tachycardia,        ............  249 

Bradycardia,        .....' 250 

Angina  pectoris, 250 

CHAPTER    XV. 

Diseases  of  the  thoracic  arteries,       .         .         .         .         .     •  .        .        .         .  254 

Aortitis, 254 

Atheroma  of  the  aorta, 254 


xvi  CONTENTS. 

PAGE 

Aortic  or  thoracic  aneurism, 256 

Aneurism  of  the  sinuses  of  Valsalva, 257 

Aneurism  of  the  arch  of  the  aorta 257 

Aneurism  of  the  descending  aorta, 257 

Coarctation  of  the  aorta 266 

Solid  mediastinal  tumors, 267 


DISEASES   OF   THE   THKOAT. 
CHAPTER  XVI. 


The  throat,  .... 

Examination  of  the  fauces, 
Laryngoscopy,     . 

Obstacles  to  laryngoscopy,  . 

Infra-glottic  laryngoscopy, 


271 
271 

272 
289 
292 


CHAPTER   XVII. 

The  throat,  continued,       .  293 

The  larynx  and  rhinoscopy,         .........  293 

Examination  of  the  trachea 300 

Rhinoscopy, 301 

Anterior  rhinoscopy, 301 

Posterior  rhinoscopy 302 

Obstacles  to  posterior  rhinoscopy, 304 

Vault  of  the  pharynx  and  posterior  nasal  cavities, 307 

CHAPTER  XVIII. 

Diseases  of  the  fauces, 311 

Acute  sore  throat 311 

Erysipelatous  sore  throat, 314 

Rheumatic  sore  throat, 316 

Acute  rheumatic  sore  throat 316 

Chronic  rheumatic  sore  throat, 318 

Sore  throat  of  small -pox,    .  321 

Sore  throat  of  measles,         ...  ,  322 

Sore  throat  of  scarlet  fever,         .........  323 

Simple  membranous  sore  throat, 324 

CHAPTER  XIX. 

Diseases  of  the  fauces,  continued 328 

Diphtheria, 328 

CHAPTER   XX. 

Diseases  of  the  fauces,  continued, 339 

Acute  follicular  pharyngitis, 339 

Chronic  follicular  pharyngitis,  .........  340 

Acute  follicular  glossitis, 347 


CONTENTS. 


XV1.1 


Chronic  follicular  glossitis, 
Scrofulous  sore  throat,  -  . 

Acute  tubercuar  sore  throat, 
Syphilitic  sore  throat, 

Syphilitic  sore  throat  in  infants, 


CHAPTER  XXI. 


Diseases  of  the  fauces,  continued, 

Diseases  of  the  uvula,  ...... 

Acute  inflammation  and  oedema  of  the  uvula,    . 

Chronic  inflammation  and  elongation  of  the  uvula 

Malformation  and  new  growths  of  the  uvula, 

Leucoplakia  buccalis,  . 
Acute  tonsillitis, 
Phlegmonous  tonsillitis, 
Hypertrophy  of  the  tonsils, 
Concretions  in  the  tonsils, 
Mycosis  of  the  throat, 
Tubercular  ulceration  of  the  tonsils, 
Cancer  of  the  tonsil,   . 


CHAPTER  XXII. 

Diseases  of  the  pharynx,   . 

Foreign  bodies  in  the  pharynx, 
Retro-pharyngeal  abscess, 
Tumors  of  the  pharynx, 
Cancer  of  the  pharynx, 
Neuroses  of  the  pharynx,    . 

Anaesthesia  of  the  pharynx, 

Hyperassthesia  of  the  pharynx, 

Paresthesia  of  the  pharynx, 

Spasm  of  the  pharynx, 

Paralysis  of  the  pharynx, 
Scalds  and  burns  of  the  pharynx, 
Swallowing  the  tongue, 
Diseases  of  the  valeculse  and  pyriform  sinuses. 


PAGE 

.  347 
.  348 
.  350 
,  353 
.  356 


358 
358 
358 
358 
359 
360 
362 
368 
370 
375 
376 
378 
380 


382 
382 
383 
386 
386 
388 
388 
388 
889 
390 
391 
392 
392 
393 


CHAPTER  XXIII. 

Diseases  of  the  larynx, 394 

Acute  laryngitis, .  394 

Subacute  laryngitis, *.         .  397 

Traumatic  laryngitis, 398 

Chronic  laryngitis, 398 

Trachoma  of  the  vocal  cords, 408 

Phlebectasis  laryngea, 409 

CHAPTER  XXIV. 

Diseases  of  the  larynx,  continued, 411 

Membranous  croup, 411 


XV111 


CONTENTS. 


CHAPTER  XXV. 

Diseases  of  the  larynx,  continued.    ..... 

Phlegmonous  laryngitis, 

Erysipelatous  laryngitis, 

Abscess  of  the  larynx, 

(Edema  of  the  larynx,         ...... 

Chondritis  and  perichondritis  of  the  laryngeal  cartilages 

Tubercular  laryngitis, 

Syphilitic  laryngitis, 

Syphilitic  laryngitis  in  infants, 


PAGE 

,  427 
,  427 
.  428 
.  429 
.  430 
.  433 
.  434 
.  443 
.  449 


CHAPTER  XXVI. 

Diseases  of  the  larynx,  continued, 451 

Lupus  of  the  larynx, 451 

Lepra  of  the  larynx, 454 

Hypertrophy  of  the  larynx 455 

Laryngitis  of  small-pox,     .         .         .         .         .         .                  .         .         .  455 

Laryngitis  of  measles, 455 

Laryngitis  of  scarlet  fever, 455 

Chronic  stenosis  of  the  larynx 456 

Stenosis  of  the  trachea,       . 460 

Tracheitis, 460 


CHAPTER    XXVII. 


Diseases  of  the  larynx,  continued,    . 

Morbid  growths  in  the  larynx,   . 
Benign  tumors  of  the  larynx. 
Malignant  tumors  of  the  larynx, 

E version  of  the  ventricle  of  Morgagn 

Tracheal  tumors, 

Post- tracheotomy  vegetations,   . 

Involution  of  the  trachea,  . 

Tracheocele,         .         ... 

Syphilis  of  the  trachea, 


463 
463 
465 

476 
483 
483 
485 

485 
486 

487 


CHAPTER  XXVIII. 

Diseases  of  the  larynx,  continued,    . 489 

Fracture  of  the  larynx, 489 

Dislocation  of  the  larynx.  ..........  490 

Foreign  bodies  in  the  larynx,     . 490 

Foreign  bodies  in  the  trachea, 492 

Spasm  of  the  glottis,   . 496 

Spasms  of  the  larynx  in  adults, 497 

Irritative  cough,  ...........   498 

Nervous  cough,    ............  498 

Anaesthesia  of  the  larynx,  ..........  499 

Hypereesthesia,  paresthesia,  and  neuralgia  of  the  larynx,       .         .         .  500 
Chorea  laryngis, 501 


CONTENTS. 


xix 


PAdiS 

Spasm  of  the  vocal  cords, 502 

Falsetto  voice, 503 

Laryngeal  vertigo, .  504 


CHAPTER  XXIX. 

Diseases  of  the  larynx,  continued,    ...... 

Paralysis  of  the  thyro-epiglottic  and  ary-epiglottic  muscles, 
Paralysis  of  the  crico-thyroid  muscles,       .... 

Paralysis  of  the  thyro-arytenoid  muscles, 
Bilateral  paralysis  of  the  lateral  crico-arytenoid  muscles, 
Unilateral  paralysis  of  the  lateral  crico-arytenoid  muscles, 
Paralysis  of  the  arytenoid  muscle,     ..... 

Bilateral  paralysis  of  the  posterior  crico-arytenoid  muscles, 
Unilateral  paralysis  of  the  posterior  crico-arytenoid  muscles, 
Ancli3dosis  of  the  arytenoid  cartilages,      .... 

Atrophy  of  the  vocal  cords,         .         .  . 


505 
505 
506 
507 
508 
510 
511 
511 
514 
514 
515 


DISEASES   OF  THE   NOSE 

CHAPTER  XXX. 

Diseases  of  the  nasal  cavities,   .         . 519 

Influenza, 519 

Rhinitis,      .         .         . 522 

Simple  acute  rhinitis, 522 

Traumatic  rhinitis, 526 

Chronic  rhinitis, 527 

Simple  chronic  rhinitis, 528 


CHAPTER   XXXI. 

Diseases  of  the  nasal  cavities,  continued, 
Rhinitis,  continued,   .... 
Chronic  rhinitis,  continued, 
Intumescent  rhinitis,     . 
Hypertrophic  rhinitis,  . 
Submucous  infiltration  at  the  sides  of  the  vomer 
Atrophic  rhinitis,  .  .         .         , 


531 
531 
531 

531 
540 

'547 
547 


CHAPTER  XXXII. 

Diseases  of  the  nasal  cavities,  continued, 553 

Hay  fever, 553 

Furunculosis  of  the  nose, 558 

Epistaxis, 559 


CHAPTER  XXXIII. 
Diseases  of  the  nasal  cavities,  continued, 


Nasal  mucous  polypi, 
Nasal  fibrous  polypi, 


564 
564 
569 


XX 


CONTENTS. 


PAGE 

Nasal  papillary  tumors,        ...  569 

Nasal  vascular  tumors,        .  570 

Nasal  osseous  cysts,     . 570 

Nasal  cartilaginous  tumors, 571 

Nasal  bony  tumors, 571 

Nasal  malignant  tumors, 572 

CHAPTER  XXXIV. 

Diseases  of  the  nasal  cavities,  continued, 574 

Syphilis  of  the  nose, 574 

Congenital  syphilis  of  the  nose, 577 

Tuberculosis  of  the  nares,    . 578 

Empyema  of  the  antrum,    . 579 

Empyema  of  the  sphenoidal  sinuses, „  583 

Inflammation  of  the  frontal  sinus 584 

Chronic  suppurative  ethmoiditis.  585 

Lupus  of  the  nares,      ....  587 

Ehinoscleroma,    . 588 

Glanders 589 

Nasal  affections  in  acute  diseases 591 

Perverted  sense  of  smell,    . 591 

Parosmia, 591 

Anosmia, 591 


CHAPTER   XXXV. 

Diseases  of  the  nasal  cavities,  continued, 
Congenital  deformity  of  the  nose, 
Fractures  of  the  nose,  .... 

Dislocation  of  the  nasal  bones,  . 

Deflection  of  the  nasal  septum, 

Ecchondroma  and  exostosis  of  the  nasal  septum, 

Perforation  of  the  nasal  septum, 

Haematoma  of  the  nasal  septum, 

Abscesses  of  the  nasal  septum,     . 
Foreign  bodies  in  the  nose, 
Rhinoliths,  ...... 

Myasis  narium  or  maggots  in  the  nose, 


593 
593 
593 
594 
594 
597 
601 
602 
603 
603 
604 
605 


CHAPTER  XXXVI. 

Diseases  of  the  nasopharynx,  . 607 

Rhino-pharyngitis, 607 

Throat  deafness, 610 

Hypertrophy  of  the  pharyngeal  tonsil, 613 

Retronasal  fibrous  tumors,           .                  620 

Retronasal  fibro- mucous  tumors, 624 

Retronasal  cartilaginous  tumors, 625 

Malignant  tumors  of  the  naso-pharynx 625 

Cystic  tumors  of  the  naso-pharynx,   ........  626 


CONTENTS. 


xxi 


DISEASES     OF     THE     THYROID     GLAND      AND 

(ESOPHAGUS. 


THE 


CHAPTER  XXXVII. 


Goitre, 

Exophthalmic  goitre, 
Oesophagitis, 

Acute  oesophagitis, 

Chronic  oesophagitis, 
Stricture  of  the  oesophagus, 
Compression  of  the  oesophagus, 
Spasm  of  the  oesophagus,  . 
Paralysis  of  the  oesophagus, 
Foreign  bodies  in  the  oesophagus, 
Parsesthesia  of  the  oesophagus, 


PAGE 

.  629 
.  632 
.  632 
.  632 
.  633 
.  634 
.  637 
.  637 
.  638 
.  640 
.  642 


APPENDIX. 

Formulas  for  prescriptions,         ..........  645 

Gargles, .        . 647 

Sedatives,      .  647 

Astringents, 647 

Stimulants, 647 

Antiseptics 3 647 

Trochisci  or  lozenges, 647 

Sedatives, 647 

Demulcents, 648 

Astringents, 648 

Stimulants,  ............  648 

Antiseptics, = 649 

Vapor  inhalations, „  649 

Sedatives,      .  650 

Antispasmodics, 650 

Mild  stimulants, 650 

Strong  stimulants, 651 

Spray  inhalations, 651 

Sedatives, 651 

Astringents  and  stimulants, 652 

Haemostatics, .         .         .         .         .  653 

Antiseptics, 653 

Dry  inhalations,  .  654 

Sedatives,      .  654 

Stimulants .         .   654 

Fuming  inhalations 654 

Sedatives, 655 

Stimulants, 655 

Pigments, 655 

Local  anaesthetics 655 


xxn  CONTENTS. 

PAGE 

Astringents, 655 

Stimulants  and  caustics, 656 

Antiseptics, 656 

Insufflations, 656 

Sedatives, 656 

Antiseptics  and  stimulants, 657 

Astringents  and  stimulants .         .  657 

Nasal  douches, 658 


LIST  OF  ILLUSTRATIONS. 


FIG. 


PAGE 

1.  Kegions  of  the  chest, 4 

2.  Begions  of  the  chest, 5 

3.  Outline  of  the  chest, 10 

4.  Quain's  stethometer, .17 

5.  Carroll's  stethometer,         .  .17 

6.  Flint's  cyrtometer,     . .  18 

7.  Sph'ometer, 18 

8.  Allison's  stethogoniometer 18 

9.  Hammond's  haernadynamometer, 19 

10.  Flint's  hammer  and  pleximeter, .  21 

11.  Camman's  stethoscope, 32 

12.  Ingals'  emballometer, .  33 

13.  Solid  wooden  stethoscope,  .  -   .         .         .         .         .         .         .36 

14.  Knight's  stethoscope, .36 

15.  Allison's  differential  stethoscope, 37 

16.  Phthisis, 47 

17.  Bronchial  rales, 49 

18.  Acute  pleurisy, 53 

19.  Curved  line  of  flatness  in  pleurisy,  posterior  view,  .         .         .         .64 

20.  Curved  line  of  flatness  in  pleurisy,  anterior  view, 65 

21.  Subacute  pleurisy, 73 

22.  Cabot's  drainage  tubes, .79 

23.  Strong's  drainage  tubes,   ..........  79 

24.  Ingals'  flat  trocar, 79 

25.  Ingals'  drainage  tubes, 81 

26.  Pneumo-hydrothorax,        ..........  86 

27.  Pneumonia,        .         . 117 

28.  Tubercle, 157 

29.  Tubercle  bacilli,  colored  plate,          ........  168 

30.  Globe  nebulizer, .  174 

31.  Physiological  action  of  the  heart, 181 

32.  Rhythm  of  the  heart, 183 

33.  Areas  of  endo-cardial  murmurs,        ........  198 

34.  Auricular  systole, •  201 

35.  Ventricular  systole, 202 

36:  Marey's  sphygmograph, 208 

37.  Normal  radial  pulse,  tracings,  ........  208 

38.  Normal  radial  pulse,  tracings, 208 

39.  Aortic  obstruction, 209 

40.  Aortic  obstruction,    ............  209 

41.  Mitral  regurgitation, 209 


XXIV 


LIST  OF  ILLUSTRATIONS. 


FIG. 

42. 
43. 
44. 
4.-). 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 


68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 


80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
9-2 


Aneurism.  ........ 

Aortic  regurgitation.         ...... 

Aortic  regurgitation  and  obstruction, 

Cardiac  hypertrophy  in  Blight's  disease. 

Tracing  of  the  senile  pulse,       ..... 

Mitral  constriction,  tracing,     ..... 

Mitral  constriction  and  aortic  regurgitation,  tracing, 
Mitral  hypertrophy  and  dilatation,  .... 

Turck's  tongue  depressor,  ..... 

Pocket  tongue  depressor,  ...... 

Bosworth's  tongue  depressor,   ..... 

Throat  mirrors  for  laryngoscopy,      .         .         . 
Sc-hrotter's  head  band  with  nasal  rest, 
Krishaber's  illuminator,   ...... 

Modified  Mackenzie's  rack -movement  bull's-eye  condenser, 
Modification  of  Mackenzie's  illuminator, 
Laiyngoscopic  reflector,    ...... 

Position  of  the  head  giving  the  best  view  of  the  larynx, 
Position  of  the  head  giving  a  poor  view  of  the  larynx, 
Lai  yngoscopic  mirror  in  position,    .... 

Brim's  pincette,         ....... 

Infra-glottic  laryngoscopy,         ..... 

Relative  relations  of  the  larynx  and  its  image, 
Normmal  larynx  in  respiration,         .... 

Pitcher-shaped  inter-arytenoid  fold, 
Lapping  of  arytenoid  cartilages  in  phonation, 
Cushion  of  epiglottis,         ...... 

Pointed  epiglottis,     ....... 

Jews' -harp  epiglottis,         ...... 

Larynx  of  a  woman  in  respiration,  .... 

View  of  left  side  of  larynx,      ..... 

Normal  larynx  of  woman  in  formation  of  head  tones, 
View  of  posterior  wall  of  trachea,     .... 

View  of  anterior  wall  of  trachea,      .... 

Ingals'  nasal  speculum,     ...... 

Jarvis'  nasal  speculum,     ...... 

Sajous'  nasal  speculum.     ...... 

Cross  section  of  head  showing  ethmoid  cells  and  nasal  cavities. 
Fraenkel's  rhinoscope,       ...... 

Position  for  rhinoscopy,    ...... 

Rubber  palate  retractor,     ...... 

Porcher's  self-retaining  uvula  and  palate  retractor, 
Palate  retractor,         ....... 

Rhinoscope  with  uvula  holder,  .... 

Rhinoscopic  image,   ....... 

Adenoid  tissue  at  vault  of  the  pharynx, 
Pharyngeal  bursa,      ....... 

Chronic  follicular  pharyngitis, 

Modification  of  Shurly' s  battery, 

Ingals'  cautery  electrodes,         ..... 

Perforation  of  the  palate,  syphilitic, 


LIST  OF  ILLUSTRATIONS. 


xxv 


FIG.  PAGE 

93.  Scissors  for  amputating  the  uvula, 359 

94.  Mathieu's  tonsillitome, 372 

95.  Mathieu's  tonsillitome,  oblique  fenestra 372 

96.  Ingals'  tonsil  forceps, 373 

97.  Fibroma  of  pharynx, 386 

98.  Superficial  ulcers  of  the  vocal  cords, 395 

99.  Superficial  ulceration  of  the  epiglottis, 395 

100.  Mackenzie's  laryngeal  lancet,  .         .         .         .         .        ..         .         .  397 

101.  Catarrhal  ulcer  of  the  vocal  cord, 399 

102.  Chronic  catarrhal  laryngitis,  with  deformity, 399 

103.  Chronic  catarrhal  laryngitis, 401 

104.  Catarrhal  laryngitis,  with  deformity, 401 

105.  Subglottic  oedema,     . 401 

106.  Davidson's  atomizers,  set  No.  66, 405 

107.  Ingals'  laryngeal  applicator,     .........  405 

108.  Davidson's  atomizer,  No.  59  old  style, .  406 

109.  Trachoma  of  vocal  cords,  .         . 408 

110.  Ingals'  chromic  acid  applicator  and  handle, 409 

111.  Ingals'  galvano- cautery  handle, 409 

112.  O'Dwyer's  intubation  instruments, 418 

113.  Henrotin's  gag,  ...........   419 

114.  Waxham's  gag, 419 

115.  Allingham's  gag, 419 

116.  O'Dwyer's  extractor,         .         .         .  "  .         .         .         .         .         .   420 

117.  Abscess '  of  the  larynx, 429 

118.  Infra-glottic  abscess  of  the  larynx,  .......  430 

119.  Infra-glottic  abscess  of  the  larynx,  twelve  hours  after  opening,     .         .  430 

120.  CEdema  of  the  larynx, 432 

121.  Tubercular  laryngitis,       ..........   435 

122.  Tubercular  laryngitis,  pyriform  swelling  of  the  arytenoids,  .         .  435 

123.  Tubercular  laryngitis,  pyriform  swelling  of  the  arytenoids,  .         .  435 

124.  Tubercular  laryngitis, 435 

125.  Incipient  tubercular  laryngitis,         . 436 

126.  Tubercular  laryngitis, 436 

127.  Tubercular  ulceration  of  the  vocal  cords, 437 

128.  Tubercular  ulceration  of  the  vocal  cords, 437 

129.  Tubercular  ulceration  of  the  ventricular  bands, 438 

130.  Tubercular  ulceration  of  the  ventricular  bands  and  vocal  cords,    .         .  438 

131.  Tubercular  laryngitis,  sluggish  action  of  the  vocal  cords,        .         .         .   438 

132.  Tubercular  ulceration  of  the  larynx, 440 

133.  Tubercular  laryngitis,  with  syphilis, 440 

134.  Condyloma  of  the  epiglottis,     .......  .  444 

135.  Gumma  of  the  larynx,       ..........   444 

136.  Multiple  gumma  of  the  larynx, 444 

137.  Syphilitic  laryngitis, .  •  .  444 

138.  Syphilitic  laryngitis,         ...........  446 

139.  Syphilitic  ulceration  of  the  epiglottis,     ..*....  446 

140.  Syphilitic  ulceration, 446 

141.  Lupus  of  the  larynx  (Ziemssen) , 451 

142.  Lupus  of  the  larynx  (Tiirck) ,  ....:...  452 

143.  Lepra  of  the  larynx, 454 


XXVI 


LIST  OF  ILLUSTRATIONS. 


FIG. 

144  Syphilitic  laryngitis, 

145.  Syphilitic  stenosis  of  larynx,   . 

140.  [Mackenzie's  laryngeal  dilator, 

147.  Whistler's  cutting  dilator, 

148.  Tube  for  laryngotracheal  stenosis, 

149.  Mount  Bleyer's  tongue  depressor, 

150.  Papilloma  of  right  vocal  cord, 

151.  Papilloma  of  the  larynx. 

152.  Papilloma  of  vocal  cords, 

153.  Papilloma  of  vocal  cords, 

154.  Papilloma  of  the  larynx.    . 

155.  Fibroma  of  left  vocal  cord, 

156.  Fibro-cellular  tumor  of  the  larynx. 

157.  Cystic  tumor  of  the  larynx, 

158.  Cystic  tumor  of  the  larynx, 

159.  Cyst  of  the  epiglottis, 

160.  Adenoid  tumor  of  the  larynx, 

161.  Adenoid  tumor  of  the  larynx, 

162.  Cartilaginous  tumor  of  the  laryi 

163.  Vascular  tumor  of  the  larynx. 

164.  Vascular  tumor  of  the  larynx, 

165.  Laryngeal  forceps.     . 

166.  Mackenzie's  tube  forceps, 

167.  Stoerk's  laryngeal  instruments, 
16s.  Tobold's  laryngeal  knives, 

169.  Cancer  of  the  larynx, 

170.  Cancer  of  the  larynx, 

171.  Cancer  of  the  larynx, 

172.  Cancer  of  the  larynx, 

173.  Cancer  of  the  larynx, 

174.  Cancer  of  the  larynx, 

175.  Mixed  sarcoma  of  larynx. 

176.  Cancer  of  the  larynx, 

177.  Tumor  in  the  trachea, 

178.  Ingals'  punch  forceps, 

179.  Syphilitic  laryngitis, 

180.  Seller's  tube  forceps, 

181.  Bilateral  paralysis  of  the  cricothyroid  muscles, 

182.  Acute  laryngitis, 

183.  Paralysis  of  the  thyro-arytenoid  muscles, 

184.  Paralysis  of  the  lateral  crico-arytenoid  muscles, 

185.  Mackenzie's  laryngeal  electrodes, 

186.  Unilateral  paralysis  of  the  lateral  crico-arytenoid  muscles,  respiration, 

187.  Unilateral  paralysis  of  the  lateral  crico-arytenoid  muscles,  phonation,  . 

188.  Unilateral  paralysis  of  the  crico-arytenoid  muscles,         .... 

189.  Ziemssen's  laryngeal  electrodes,        ........ 

190.  Bilateral  paralysis  of  the  posterior  crico-arytenoid  muscles,    inspira- 

tion, ............. 

191.  Bilateral  paralysis  of  the  posterior  crico-arytenoid  muscles,  expiration, 

192.  Unilateral  paralysis  of  the  posterior  crico-arytenoid  muscles,  inspira- 

tion,  


512 
512 

514 


LIST  OF  ILLUSTRATIONS. 


xxvn 


FIG. 

193. 

194. 
195. 
196. 
197. 
198. 
199. 
200. 
201. 
202. 
203. 
204. 
205. 
206. 
207. 
208. 
209. 
210. 
211. 
212. 
213. 
214. 
215. 
216. 
217. 
218. 
219. 
220. 
221. 
222. 
223. 
224. 
225. 
226 
228. 
229 
230 
231 
232 
233 
234 
235 
236 
237 
238 
239 
240 


bodies 


Unilateral  paralysis  of  the  posterior  crico-arytenoid  muscles,  phona- 

tion. 

Anchylosis  of  the  arytenoid  cartilages,     . 

Powder  blower,  ..... 

Davidson's  oil  atomizer,  No.  50, 

Flat  nasal  probe  and  applicator, 

Hypertrophy  of  the  inferior  turbinated  body, 

Hypertrophy  of  the  posterior  ends  of  the  inferior  turbinated 

Ingals'  nasal  scissors,         .... 

Nasal  burrs, 

Nasal  trephines,  ..... 

Submucous  infiltration  at  sides  of  the  Tomer, 
Ingals'  nasal  syringe,         .... 

Nasal  douche,     ...... 

Nasal  douche,  traveller's, 
Galvano-cautery  handle  with  ecraseur,     . 
Ingals'  snare,     ...... 

Cotton  applicator,       ..... 

Hypodermic  syringe,  long  silver  nozzle, 

Ingals'  nasal  dressing  forceps. 

Cross  section  of  head  looking  from  behind  forward, 

Ingals'  electric  lamp, 

Brainard's  bone  drill, 

Ingals'  drainage  tubes  for  antrum, 

Cross  section  of  head, 

Curtis'  ethmoid-cell  wash-bottle, 

Ingals'  septum  forceps, 

Ingals'  septum  knife. 

Ingals'  right-angle  cutting  forceps, 

Exostosis  from  the  septum, 

Sajous'  knife, 

Nasal  spud, 


Ingals'  nasal  saw, 
Ingals'  flat  nasal  saw, 
and  227.  Sajous'  saws, 
Ingals'  heavy  bone  scissors,       .... 

Ingals'  nasal  bone  forceps,         .... 

Ingals'  nasal  spatula.  ..... 

Gross'  instruments  for  removing  foreign  bodies, 

Post-nasal  syringe, 

Curtis'  Eustachian  tube  vaporizer,   . 
Rhinoscopic  view  of  post-nasal  vegetations,     . 
Mackenzie's,  John  N. ,  post-nasal  forceps, 
Ingals'  post-nasal  snare  applicator, 
Retro-nasal  fibro-mucous  polypus, 
Sand's  oesophagotome, 
Flexible  resophageal  forceps, 
Bristle  extractor, 


514 
514 
536 
536 
537 
541 
542 
545 
546 
546 
547 
550 
551 
551 
567 
567 
568 
568 
576 
579 
581 
582 
583 
584 
586 
596 
596 
597 
598 
599 
599 
599 
599 
599 
600 
600 
600 
604 
609 
612 
614 
617 
623 
624 
636 
641 
642 


Diseases  of  the  Chest 


OHAPTEK  I. 
PHYSICAL  DIAGNOSIS. 


» 


Iisr  this  work  I  shall  first  describe  the  methods  for  detecting  disease 
which  are  based  upon  the  pathological  changes  in  the  organs  affected ; 
next  point  out  the  characteristics  and  significance  of  the  various  signs; 
and  finally  consider  the  individual  diseases. 

The  term  physical  diagnosis  is  used  to  designate  the  methods  re- 
ferred to,  whether  used  in  the  examination  of  the  chest  or  in  the  exam- 
ination of  any  other  part  of  the  body;  but  as  it  is  in  the  exploration  of 
the  chest  that  such  methods  have  yielded  the  most  brilliant  results,  it  is 
now  customary  to  apply  the  term  physical  diagnosis  simply  to  the  ex- 
amination of  the  thorax. 

It  is  in  this  limited  sense  that  We  shall  generally  use  it,  though  it 
will  also  be  applied  to  the  examination  of  the  upper  air  passages. 

DIVISIONS   OF   THE   CHEST. 

To  simplify  the  study,  and  to  enable  us  to  fix  accurately  in  mind  the 
position  of  the  intra-thoracic  organs,  the  chest  has  been  divided  into  a 
number  of  regions  which  are  purely  arbitrary,  and  their  boundaries  vary 
with  different  authors. 

J.  M.  Da  Costa  divides  the  chest  into  the  anterior,  the  posterior,  and 
two  lateral  regions,  and  subdivides  these  into  upper  and  lower  regions. 
He  locates  signs  present  in  these  regions  by  certain  fixed  marks  which 
may  be  found  on  the  surface  of  the  chest.  For  instance,  anteriorly,  a 
sign  may  be  located  in  a  certain  intercostal  space,  or  beneath  a  rib  or 
the  clavicle,  at  a  given  distance  from  the  sternum.  Posteriorly,  a  sign 
may  be  located  in  a  similar  manner  with  reference  to  the  spinous  proc- 
esses, or  to  the  angles  and  the  borders  of  the  scapula.  Such  a  division 
is  well  enough  for  the  record  of  cases,  but  it  does  not  aid  us  in  remem- 
bering the  location  of  the  intra-thoracic  organs. 

The  division  here  adopted  is  similar  to  one  quite  commonly  taught, 
with  only  such  changes  as  make  it  plainer  and  more  easily  remembered. 

"While  learning  these  boundaries,  one  should  fix  in  mind  the  exact 
position  of  the  intra-thoracic  organs. 

We  divide  the  chest  primarily  into  anterior,  posterior,  and  lateral 
regions,  and  subdivide  as  follows. 


4  PHYSICAL  DIAGNOSIS. 

Upon  the  anterior  surface  on  either  side,  from  above  downward,  we 
have  the  supra-clavicular,   clavicular,    infra-clavicular,  mammary,  and 

infra-mammary  regions :  between  these  two  lateral  groups  we  find  the 
supra-sternal  above  the  line  of  the  clavicles,  and  the  sternal  region  sub- 
divided into  the  superior-sternal  and  inferior-sternal. 

The  posterior  portion  of  the  chest,  on  each  side,  is  subdivided  into 
the  supra-scapular  and  the  scapular  regions,  between  these  the  inter-scap- 
ular region,  and  below  the  scapulae  the  infra-scapular  regions  (Fig.  2). 

Laterally  we  have  the  axillary  and  the  infra-axillary  regions. 

I  .......  *  \ 


F9  4  I 


I    1 


Fig.  1. — A,  Supra-clavicular  region;  B,  clavicular  region  ;  C,  infra-clavicular  region  ;  D,  mam- 
mary region  ;  E.  infra-mammary  region  :  F,  superior-sternal  region  ;  G,  inferior-sternal  region. 
The  wavy  lines  represent  the  borders  of  the  lungs  and  the  pulmonary  fissures.  The  dotted  lines 
correspond  to  the  outlines  of  the  various  organs,  viz..  trachea,  aorta,  bronchial  tubes,  heart,  liver, 
spleen,  and  stomach.  The  very  dark  shading  over  the  solid  viscera  shows  the  normal  areas  of 
flatness,  and  the  shading  next  lighter  over  the  upper  part  of  the  liver  shows  the  hepatic  dulness. 
The  black  rectangular  spots  near  the  third  rib  correspond  to  the  position  of  the  valves  of  the  heart. 

The  supra-clavicular  region  corresponds  to  that  portion  of  the 
pleural  cavity  which  extends  above  the  clavicles.  It  is  triangular  in 
form,  with  its  base  internal,  its  apex  external.  It  is  bounded  above  by  a 
line  drawn  from  the  upper  ring  of  the  trachea  outward  to  the  junction 
of  the  middle  with  the  external  third  of  the  clavicle.  The  inferior 
boundary  of  this  region  corresponds  to  the  tipper  margin  of  the  inner 
two-thirds  of  the  clavicle.  The  internal  boundary  corresponds  to  the 
sterno-cleido-mastoid  muscle.  This  region  contains,  on  either  side,  the 
apex  of  the  lung  and  portions  of  the  subclavian  artery  and  vein.   • 

The  clavicular   region  corresponds  to  the  inner  two-thirds   of 


DIVISIONS   OF  THE   CHEST.  5 

the  clavicle  and  is  bounded  above  and  below  by  the  borders  of  the  bone. 
It  contains  lung  tissue.  Upon  the  right  side,  externally  we  find  the 
subclavian  artery,  and  at  the  inner  extremity  the  arteria  innominata 
and  the  recurrent  laryngeal  nerve  as  it  passes  up  to  supply  the  muscles 
of  the  larynx.  Aneurisms  in  this  locality,  by  pressing  upon  this  nerve, 
give  rise  to  serious  symptoms  due  to  paralysis  or  spasm  of  the  glottis. 
Upon  the  left  side,  at  the  inner  end  of  this  region  we  find  the  carotid 
and  the  subclavian  arteries,  deeply  seated  and  running  almost  at  right 
angles  with  the  clavicle. 

The  infra-clavicular  region  is  bounded  above  by  the  clavicle, 
internally  by  the  margin  of  the  sternum,  and   externally  by  a  straight 


6'cix/i  it la  r  ;   UX 


& 


-i  nX  e  r 


Fig.  2.— The  wavy  lines  correspond  to  the  borders  and  fissures  of  the  lungs.  The  dotted  line 
across  the  scapular  region  indicates  the  position  of  the  spine  of  the  scapula.  The  dotted  lines  and 
shaded  areas  in  the  infra-scapular  regions  indicate  the  position  of  the  liver  and  spleen. 

line  let  fall  from  the  outer  extremity  of  the  clavicular  region,  and  pass- 
ing about  an  inch  externally  from  the  nipple.  It  is  bounded  below  by 
the  lower  margin  of  the  third  rib.  This  region  contains  lung  tissue  on 
either  side.  On  the  right,  close  to  the  border  of  the  sternum,  we  find 
portions  of  the  ascending  aorta  and  of  the  descending  vena  cava.  Just 
beneath  the  second  costal  cartilage,  we  find  the  right  bronchus  as  it 
passes  into  the  right  lung.  Upon  the  left,  in  the  second  intercostal 
space,  close  to  the  margin  of  the  sternum,  the  pulmonary  artery  is 
located.  In  the  same  space  is  found  the  left  bronchus,  which  inclines 
more  downward,  and  is  located  lower  than  the  main  bronchus  on  the 
opposite  side.  A  portion  of  the  base  of  the  heart  occupies  the  internal 
inferior  angle  of  this  region. 

The  mammary  region,  which  lies  immediately  below  the  preced- 
ing, is  bounded  internally  by  the  margin  of  the  sternum,  externally  by 


3  PHYSICAL   DIAGNOSIS. 

a  continuation  of  the  line  which  bounds  the  infra-clavicular  region,  and 
inferiority  by  the  lower  margin  of  the  sixth  rib.  We  may  easily  remem- 
ber the  boundaries  of  tne  infra-clavicular  and  the  mammary  regions,  by 
recollecting  that  Ave  have  three  ribs  in  each.  The  inferior  border  of  the 
third  rib  forms  the  lower  boundary  of  the  upper  region  and  the  lower 
margin  of  the  sixth  rib  bounds  the  lower  region  inferiorly.  This  region 
contains  lung  tissue  on  both  sides.  On  the  right,  the  thin  margin  of  the 
lung,  which  overlaps  the  liver,  reaches  to  the  sixth  interspace,  and  ex- 
tends even  lower  in  full  inspiration.  Deeper  seated  we  find  the  upper 
convex  surface  of  the  liver,  carrying  the  diaphragm  above  it,  as  high  as 
the  fourth  intercostal  space.  The  nipple  is  usually  located  in  the  fourth 
intercostal  space;  therefore,  we  expect  to  find  the  upper  border  of  the 
liver  beneath  it.  A  small  portion  of  both  the  right  auricle  and  the  right 
ventricle  extends  into  this  region.  In  the  upper  part  of  the  left  mam- 
mary region,  the  lung  tissue  is  in  front  as  low  as  the  fourth  rib.  Here 
the  border  of  the  lung  jjasses  outward  and  downward  to  the  fifth  rib, 
leaving  between  it  and  the  median  line  a  triangular  space  in  which  the 
heart  and  its  investing  membrane  are  superficial. 

The  ixfra-mammary  region  is  bounded  externally  by  a  continua- 
tion of  the  outer  boundary  of  the  mammary  region;  above  by  the  lower 
margin  of  the  sixth  rib,  and  internally  and  inferiorly  by  the  margin  of 
the  sternum  and  the  lower  borders  of  the  false  ribs.  This  region  con- 
tains, on  the  right  side,  the  liver,  and  occasionally  the  inferior  margin  of 
the  lung  during  full  inspiration.  On  the  left  side,  near  the  sternum, 
we  find  a  portion  of  the  left  lobe  of  the  liver;  a  little  farther  outward, 
near  the  middle  of  the  region,  we  have  the  stomach;  in  the  outer  third 
is  a  portion  of  the  spleen.  The  stomach  and  the  spleen  usually  extend 
as  high  as  the  sixth  rib. 

The  mammillary  or  nipple  line  is  a  vertical  line  drawn  through  the 
nipple,  and,  according  to  some  authors,  it  forms  the  external  boundary 
of  the  infra-clavicular,  mammary,  and  infra-mammary  regions. 

The  regions  between  the  lateral  portions  of  the  anterior  surface  of 
the  chest  are  three  in  number. 

The  supra-sterxal  regiox,  the  first  counting  from  above,  is 
bounded  inferiorly  by  the- upper  end  of  the  sternum,  or  inter-clavicular 
notch;  laterally  by  the  sterno-cleido-mastoid  muscles;  and  above  by  the 
first  ring  of  the  trachea.  The  most  important  organs  in  this  region  are 
the  trachea  and  the  thyroid  gland,  the  lobes  of  which  lie  on  each  side  of 
the  trachea  and  are  connected  by  the  isthmus  in  the  upper  part  of  this 
region.  Here  are  also  found  certain  small  veins  and  arteries  which  are 
of  interest  to  the  surgeon.  In  the  lower  right  angle  of  this  region  the 
innominate  artery  is  found,  and  in  the  inter-clavicular  notch  we  can 
frequently  feel  the  arch  of  the  aorta. 

The  superior-sternal  regiox,  next  in  order,  is  bounded  below 
by  a  line   connecting  the   lower  margins    of   the   third   ribs,  and   lat- 


DIVISIONS  OF  THE  CHEST.  7 

erally  by  the  borders  of  the  bone.  This  region  contains  lung  tissue. 
Superficially,  the  inner  or  anterior  margin  of  each  lung  reaches  the 
median  line.  Deeper,  we  find  the  descending  vena  cava,  the  ascending, 
the  transverse,  and  a  part  of  the  descending  portion  of  the  arch  of  the 
aorta,  and  at  the  left  a  portion  of  the  pulmonary  artery.  At  a  point 
opposite  the  second  costo-sternal  junction  is  the  bifurcation  of  the 
trachea.      » 

The  infeeioe-stee^al  eegiox,  known  also  as  the  sternal  region, 
has  for  its  boundaries  the  borders  of  all  that  portion  of  the  sternum 
lying  below  the  third  rib.  In  it  the  anterior  margin  of  the  right  lung 
corresponds  to  the  median  line,  and  is  superficially  situated.  But  the 
corresponding  margin  of  the  left  lung  recedes  from  the  median  line  at 
the  level  of  the  fourth  rib,  passing  outward  and  downward,  leaving  a 
triangular  space  between  it  and  the  margin  of  the  right  lung.  In  this 
space  the  right  ventricle  of  the  heart  is  superficial.  In  the  upper  part 
of  this  region  we  find  a  large  portion  of  the  right  auricle  and  the  origin 
of  both  the  aorta  and  the  pulmonary  artery.  The  portions  of  the  left 
side  of  the  heart  which  present  anteriorly  lie  to  the  left  of  this  region. 

In  this  region  we  find  jDortions  of  the  four  sets  of  valves  which  guard 
the  orifices  of  the  heart  (Fig.  1).  At  the  left  edge  of  the  sternum,  under 
the  third  rib,  are  the  pulmonary  valves  ;  a  trifle  lower,  beneath  the 
centre  of  the  sternum,  are  located  the  aortic  valves;  lower  yet, at  its  left 
border  in  the  third  intercostal  space,  we  find  the  mitral  valves.  We 
locate  the  tricuspid  valves  beneath  the  middle  of  the  sternum  on  a  line 
with  the  fourth  costo-sternal  articulation.  These  valves  lie  so  closely 
that  a  circle  scarcely  more  than  an  inch  in  diameter  will  include  all  of 
them,  and  a  circle  of  half  that  diameter  will  embrace  a  portion  of  each. 

At  the  lower  part  of  this  region  we  have  a  portion  of  the  liver  and 
of  the  attachment  of  the  pericardium  to  the  diaphragm. 

The  mesosternal  line  is  an  imaginary  line  passing  down  the  centre  of 
the  sternum. 

The  sternal  lines  of  the  right  and  left  sides  correspond  to  the  borders 
of  the  sternum. 

Posteriorly  are  the  supra-scapular  and  the  scapular  regions  on  each 
side,  extending  from  the  second  to  the  seventh  rib  and  corresponding 
very  nearly  to  the  outlines  of  the  scapula  when  the  patient's  arms  are 
hanging  loosely  by  his  sides  (Fig.  2). 

The  sttpea-scaptjlae  '  eegiox  corresponds  to  the  supra-spinous 
fossa.     It  is  occupied  by  lung  tissue. 

The  scapulae  eegiox  corresponds  to  the  infra-spinous  fossa.  It  is 
occupied  by  lung  tissue. 

The  inter-scapulae  eegion  lies  between  the  borders  of  the  scapulae 
divided  by  the  spinous  processes  of  the  vertebrae,  and  extends  from  the 
level  of  the  second  dorsal  vertebra  to  the  level  of  the  seventh.  It  con- 
tains lung  substance,  the  main  bronchi,  and  the  bronchial  glands.     The 


8  PHYSICAL  DIAGNOSIS. 

descending  aorta  runs  along  the  left  of  the  spinal  column,  beside  the 
oesophagus.     The  trachea  bifurcates  opposite  the  third  dorsal  vertebra. 

In  the  three  preceding  regions  the  chest  walls  are  very  thick. 

The  INFEA-SCA.PULAB  REGION  on  either  side  is  bounded  internally 
by  the  spinous  processes  of  the  vertebra-:  externally  by  a  vertical  line 
let  fall  from  the  inferior  angle  of  the  scapula:  above  by  the  lower  mar- 
gin of  the  scapular  and  inter-scapular  regions,,  which  corresponds  to  the 
seventh  rib;  and  below  by  the  inferior  margin  of  the  false  ribs.  This 
region  contains  lung  tissue  on  either  side,  extending  to  the  tenth  or  to 
the  eleventh  rib.  Below  the  margin  of  the  lung,  on  the  right  side,  we 
have  the  liver;  on  the  left  side,  the  intestines  are  superficial  near  the 
middle  jDortion  of  the  region,  and  externally  we  find  the  spleen  (Fig.  2). 
The  kidneys  are  located  near  the  spinal  column  on  either  side.  The 
left  kidney  extends  an  inch  higher  than  the  right,  and  its  upper  extrem- 
ity is  frequently  found  in  this  region. 

Laterally  we  have  two  regions,  the  axillary  and  the  infra-axillary. 

The  axillary  region  is  bounded  below  by  a  line  drawn  from  the 
lower  margin  of  the  mammary  region  backward  to  the  inferior  angle  of 
the  scapula:  above  by  the  axilla;  in  front  by  the  outer  boundaries  of 
the  infra-clavicular  and  the  mammary  regions;  and  posteriorly  by  the 
axillary  border  of  the  scapula.  This  region  contains  lung  tissue  on 
each  side  and,  deeply  seated,  the  main  bronchi. 

The  infra-axillary  region  is  bounded  above  by  the  axillary; 
posteriorly  by  the  outer  margin  of  the  infra-scapular  region;  anteriorly 
by  the  external  margin  of  the  infra-mammary  region ;  below  by  the  margin 
of  the  false  ribs.  On  either  side  we  find  the  lower  border  of  the  lung 
running  from  near  the  upper  anterior  angle  of  this  region  downward 
and  backward.  Below  this,  on  the  right  the  liver,  and  on  the  left  the 
spleen,  and  a  portion  of  the  stomach,  are  superficial. 

Pulmonary  Fissures. — On  each  side  at  a  point  about  three  inches 
below  the  apex  of  the  lung,  corresponding  very  nearly  to  the  inner  end 
of  the  spine  of  the  scapula,  we  find  the  beginning  of  the  pulmonary  fis- 
sure which  separates  the  upper  from  the  lower  lobe.  These  fissures  run 
obliquely  downward  and  forward  to  the  sixth  rib  near  the  mammillary 
line.  On  the  right  side  at  a  point  on  this  fissure,  four  or  five  inches 
from  the  sternum,  we  find  the  commencement  of  another  fissure,  which 
-  inward  to  the  margin  of  the  lung  near  the  fourth  costal  cartilage. 
By  this  fissure  a  small  triangular  portion  is  cut  off  from  the  lower  part 
of  the  upper  lobe  to  form  the  middle  lobe  of  the  right  lung.  The  posi- 
tions of  these  fissures  necessarily  change  considerably  with  inspiration 
and  expiration. 

It  is  a  common  error  with  students  to  suppose  that  the  interlobar 
fissures  run  in  the  opposite  direction;  that  is,  downward  and  backward 
from  the  upper  part  of  the  anterior  margins  of  the  lungs. 


METHODS  OF  EXAMINATION. 


METHODS   OF   PHYSICAL   EXAMINATION. 

The  principal  methods  of  physical  examination,  six  in  number,  are: 
Inspection,  Palpation,  Mensuration,  Succussion,  Percussion,  and  Auscul- 
tation. Unfortunately  the  majority  of  physicians  rely  for  their  diagno- 
sis almost  exclusively  upon  auscultation.  There  are  many  cases  in 
which  it  will  be  necessary  to  use  every  method  and  to  scrutinize  every 
symptom  before  one  can  arrive  at  an  accurate  diagnosis. 

The  evidences  of  disease  which  these  methods  furnish  are  known  as 
signs  or  physical  signs. 

There  is  a  marked  difference  between  symptoms  and  signs.  Sub- 
jective symptoms,  which  are  chiefly  derived  from  the  statements  of  the 
patient,  may  be  called  presumptive  evidence  of  disease,  while  objective 
signs  are  considered  positive  evidence. 

The  value  of  these  signs  will  depend  upon  a  knowledge  of  the  altera- 
tions which  produce  them. 

The  early  students  of  physical  diagnosis  noted  the  various  character- 
istics of  a  sign  accurately,  and  located  it  upon  the  surface  of  the  chest; 
then  at  the  autopsy  they  sought  to  ascertain  its  causes.  At  present  we 
only  need  to  study  the  sign  clinically,  for  its  causes  may  be  learned  from 
text-books;  however,  it  will  be  of  great  advantage,  when  possible,  to 
study  at  the  autopsy,  lesions  the  evidences  of  which  we  have  discovered 


by  physical  diagnosis. 


INSPECTION. 


By  inspection  we  learn  the  general  appearance  of  the  patient,  the 
color  of  the  integument,  the  presence  or  absence  of  subcutaneous  em- 
physema, oedema,  or  tumors,  and  the  size,  form,  and  movements  of  the 
•chest. 

Whatever  method  of  physical  diagnosis  is  employed,  it  is  necessary, 
first,  to  be  familiar  with  the  healthy  conditions  which  it  would  reveal. 

The  healthy  chest  has  a  generally  rounded  or  convex  appearance; 
the  shoulders  are  level,  the  clavicles  are  horizontal,  and  the  two  sides  are 
almost  perfectly  symmetrical;  however,  in  many  cases  more  or  less 
depression  will  be  observed  in  the  supra-clavicular  and  infra-clavicular 
regions,  and  not  infrequently  the  pectoral  muscles  are  better  developed 
on  one  side  than  on  the  other. 

In  men  a  deep  furrow  just  below  the  fifth  rib  marks  the  lower  bor- 
der of  the  pectoralis  major  muscle.  At  the  borders  of  the  sternum, 
about  an  inch  below  the  clavicles,  we  often  notice  rounded  prominences 
about  an  inch  in  diameter,  which  mark  the  position  of  the  second  costal 
cartilages.  These  are  frequently  mistaken  by  students  for  abnormal 
swellings.     In   some   patients  the   ribs   and    the   intercostal  spaces  are 


10  PHYSICAL  DIAGNOSIS. 

very  distinct,  while  in  others  they  are  hidden  by  adipose  tissue.  The 
obliquity  of  the  inferior  ribs  varies  greatly  in  different  individuals. 

In  the  fifth  intercostal  space,  about  two  inches  to  the  left  of  the 
sternum,  we  observe  the  impulse  of  the  chest  walls  caused  by  the  apex 
beat  of  the  heart. 

Occasionally  we  find  local  bulging  or  depression,  independent  of  dis- 
ease of  the  internal  organs.  The  prominent  sternum  known  as  pigeon- 
breast,  usually  due  to  violent  cough  or  obstructed  respiration,  as  from 
catarrh  or  enlarged  tonsils  in  childhood :  the  pear-shaped  chest,  due  to 
rachitis,  and  the  long,  narrow,  and  flat  chest,  which  often  results  from 
rapid  growth,  are  all  found  independent  of  intra-thoracic  disease. 

There  is  often  bulging  of  the  prgecordial  region,  especially  in  chil- 
dren.    Deep  depressions  of  the  lower  sternal  region,  and  of  the  ribs  in 


Fig.  3.— Transverse  Outlines  of  Certain  Forms  of  the  Chest  (Thompson'). 

rare  instances,  occur  in  healthy  individuals.  I  have  a  cast  taken  from 
life,  which  shows  a  depression  of  the  lower  sternal  region  from  an  inch 
and  a  half  to  two  inches  in  depth;  yet  the  individual  from  whom  it  was 
taken  enjoyed  perfect  health. 

Most  deviations  from  symmetry  in  the  two  sides  are  due  to  slight 
curvatures  of  the  spinal  column.  In  the  examination  of  a  large  number 
of  patients,  not  more  than  one  in  seven  will  be  found  with  a  perfectly 
symmetrical  chest. 

In  health,  the  respiratory  movements  are  repeated  sixteen  to  twenty 
times  a  minute  in  adults,  and  from  twenty  to  twenty-five  or  even  thirty 
times  in  children. 

Considerable  difference  in  the  form  and  in  the  movements  of  the 
chest  exists  in  persons  of  different  ages  and  sexes.     In  women  the  upper 


INSPECTION.  11 

portion  is  more  prominent  than  in  men.  The  respiratory  movements 
vary  accordingly,  being  more  marked  at  the  upper  part  in  women,  at 
the  lower  part  in  men.  This  disparity  is  most  conspicuous  in  rapid  res- 
piration. In  children  of  either  sex,  the  chest  walls  often  hardly  move  at 
all;  and  respiration  seems  to  be  performed  by  the  abdominal  muscles. 
The  respiratory  movements  in  these  three  localities  are  named  superior- 
costal,  inferior-costal,  and  abdominal  breathing. 

The  movements  of  the  chest  may  be  altered  considerably,  irrespective 
of  pulmonary  or  cardiac  disease.  In  health,  the  respiratory  movements 
are  readily  accelerated  by  active  exercise,  and  in  hysterical  patients  they 
are  nearly  always  rapid  and  superficial,  being  confined  mostly  to  the  upper 
part  of  the  chest.  In  persons  suffering  from  some  diseases  of  the  brain 
the  respiratory  movements  become  slower  and  slower  until  they  may  not 
exceed  three  or  four  per  minute.  In  hemiplegia  the  respiratory  move- 
ments are  incomplete  or  wanting,  on  the  affected  side  of  the  chest. 

Pregnancy,  ascites,  or  large  abdominal  tumors  cause  pressure  on  the 
diaphragm,  and  consequent  interference  with  respiration.  The  pain  of 
peritonitis  compels  the  patient  to  restrain  the  movements  of  the  abdom- 
inal muscles,  and  thus  confines  the  respiratory  movements  to  the. 
chest  and  renders  them  deficient  and  consequently  more  frequent. 

Often  among  the  first  signs  noticeable  on  inspecting  a  patient  with 
disease  of  the  infra-thoracic  organs  are  pallor,  cyanosis,  icterus,  pityria- 
sis, dropsy,  and  subcutaneous  emphysema. 

Pallor  of  the  surface  and  emaciation  are  seen  in  chronic  pulmonary 
disease.  Pallor  also  results  from  fatty  degeneration  of  the  heart,  and,  in 
some  cases,  from  mitral  disease. 

Cyanosis,  more  or  less  marked,  indicates  incomplete  oxidation  of  the 
blood,  due  to  obstruction  of  the  air  passages  or  to  diminution  of  breath- 
ing surface ;  also  to  affections  of  the  heart,  such  as  congenital  malfor- 
mations or  valvular  disease.  Occasionally  this  sign  results  from  inter- 
ference with  the  descent  of  the  diaphragm  by  disease  of  the  abdominal 
organs. 

Icterus  is  found  in  bilious  pneumonia  and  in  the  later  stages  of  those 
cardiac  diseases  which  cause  congestion  of  the  portal  circulation. 

Pityriasis  is  often  found  with  phthisis  pulmonalis,  but  it  also  occurs 
with  other  diseases,  and  sometimes  even  in  apparently  healthy  indi- 
viduals. 

Dropsy  due  to  recent  renal  disease  usually  shows  itself  first  in  the 
lower  eyelids,  and  subsequently  disappears  from  this  locality,  to  appear 
in  the  lower  limbs  and  in  the  backs  of  the  hands.  Dropsy  due  to  car- 
diac disease  usually  appears  first  over  the  instep,  and  gradually  extends 
upward,  involving  the  limbs,  trunk,  and  serous  cavities. 

Subcutaneous  emphysema  may  be  caused  by  internal  or  external  in- 
juries of  the  larynx,  the  trachea,  or  the  lungs.     Air  escaping  from  the 


12  PHYSICAL  DIAGNOSIS. 

larynx  or  the  trachea  causes  emphysema  in  the  region  of  the  throat. 
Rupture  of  the  air  cells  from  over-distention,  as  in  croup,  diphtheritis 
of  the  larynx,  whooping-cough,  bronchitis  in  children,  and  emphysema 
in  the  aged,  causes  subcutaneous  emphysema,  which  appears  first  in  the 
areolar  tissue  of  the  neck,  and  subsequently  extends  to  the  chest.  The 
air  in  these  cases  finds  its  way  into  the  mediastinum,  and  thence  to  the 
neck.  Subcutaneous  emphysema  from  external  injury  appears  first  on 
the  ches 

Alterations  in  the  form  and  in  the  movements  of  the  chest  may  be 
most  advantageously  studied  when  grouped  together  as  they  occur  in 
different  thoracic  diseases.  First,  let  us  consider  the  modifications  found 
in  pleurisy. 

Pleurisy  is  divided  into  three  stages:  first,  a  dry  stage;  second,  a 
stage  of  liquid  effusion  into  the  pleural  sac;  third,  the  stage  of  resolu- 
tion or  absorption.  In  the  first  stage  we  find  decubitus  upon  the  sound 
side;  respiratory  movements  rapid,  short,  and  catching. 

In  the  second  stage  we  usually  find  movements  of  the  affected  side 
diminished,  and  intercostal  depressions  less  marked  than  in  health;  im- 
pulse of  the  heart  displaced  to  the  right  or  to  the  left,  according  as  the 
left  or  the  right  pleura  is  distended. 

In  the  third  stage,  the  signs  of  the  second  Btage  gradually  subside. 
Sub-acute  pli  urisy  manifests  the  same  signs  as  acute  pleurisy,  with, 
excessive  exudation. 

Chronic 'pleurisy  at  first  manifests  signs  which  do  not  differ  from 
those  of  the  second  stage  of  acute  pleurisy.  After  absorption  or  evacu- 
ation of  the  liquid  takes  place,  the  affected  side  becomes  retracted  and 
flattened;  the  shoulder  is  depressed;  the  inner  border  of  the  scapula  pro- 
jects like  a  wing  and  respiratory  movements  are  limited. 

In  pulmonary  emphysema.,  on  first  sight  of  the  patient  we  notice  a 
dusky  hue  of  the  countenance,  often  a  sunken  condition  of  the  cheeks, 
marked  general  emaciation,  and  more  or  less  turgescence  of  the  super- 
ficial veins  of  the  neck  and  upper  extremities.  The  nostrils  dilate  on 
inspiration,  and  there  is  a  peculiar  drawing  downward  of  the  corners  of 
the  mouth.  There  is  elevation  and  drawing  forward  of  the  shoulders, 
with  anterior  curvature  of  the  spine,  giving  a  young  patient  the  stoop- 
ing appearance  of  old  age. 

Inspection  generally  reveals  the  peculiar  form  known  as  the  barrel- 
shaped  chest.  In  this  condition  the  antero-posterior  diameter  of  the 
chest  is  increased  (Fig.  3),  its  surface  is  rounded,  and  the  upper  ante- 
rior portion  stands  out  considerably  beyond  its  normal  plane.  Lat- 
erally, the  diameter  is  diminished,  and  its  inferior  portion,  in  the  region 
of  the  false  ribs,  is  more  or  less  retracted.  The  elevation  and  drawing 
forward  of  the  shoulders  cause  the  neck  to  appear  unusually  short.  The 
scaleni  and  stern o-cleido-mastoid  muscles  are  hypertrophied  and  promi- 
nent so  that  thev  stand  out  like  tense  cords,  resulting  from  excessive  use 


INSPECTION.  13 

of  these  muscles  which  elevate  and  fix  the  anterior  and  upper  part  of  the 
thorax. 

Inspiration  is  short  and  quick,  followed  by  prolonged  and  sometimes 
labored  expiration.  With  inspiration,  the  anterior  and  superior  portions 
of  the  chest  are  lifted  as  though  composed  of  a  single  bone,  and  there 
is  apparently  no  anterior  or  lateral  expansion  of  the  chest  walls,  because 
ihe  ribs  are  already  rotated  as  far  as  their  articulation  with  the  spinal 
column  will  permit.  The  ribs  have  less  obliquity,  forming  with  the 
costal  cartilages  more  obtuse  angles  than  in  the  normal  chest, 

The  intercostal  spaces  above  are  much  wider  than  usual,  but  at  the 
lower,  lateral  portion  of  the  chest  the  ribs  are  closer  together  than  in 
the  normal  condition,  sometimes  even  to  the  obliteration  of  interspaces. 
In  well-marked  cases  there  is  generally  with  inspiration  retraction  of 
the  inferior  ribs  instead  of  lateral  expansion.  This  falling  in  of  the 
thoracic  walls  is  not  noticed  if  the  disease  is  slight. 

Sometimes  we  meet  with  local  emphysema,  where  a  single  lung  or 
only  one  lobe  is  affected.  In  such  instances  we  notice  local  bulging  of 
the  chest,  with  loss  of  motion. 

In  extreme  emphysema  the  anterior  margin  of  the  left  lung  overlaps 
the  heart,  so  that  the  apex  cannot  strike  the  chest  wall,  hence  no  im- 
pulse can  be  seen.  In  milder  cases  the  impulse  may  be  seen  closer  to 
the  -sternum  than  in  health. 

Ir  pneumonia,  upon  first  glance  we  generally  notice  a  dusky  flush 
of  the  cheek  and  accelerated  respiration.  Inspection  of  the  chest  shows 
diminished  motion  over  the  diseased  organ.  This  loss  of  motion  may  be 
marked,  but  is  seldom  or  never  complete. 

In  pulmonary  phthisis,  the  signs  obtained  by  inspection  are  of  con- 
siderable value.  If  the  case  is  advanced  the  chest  wall  over  the  diseased 
lung  will  be  depressed  and  its  movements  restricted,  in  phthisis  more 
apt  to  orcur  at  the  apex,  and  contrary  to  the  general  belief,  quite  as 
commonly  upon  the  right  as  upon  the.  left  side.  These  phenomena  are 
due  to  local  shrinkage  and  loss  of  pulmonary  elasticity. 

In  pneumothorax  we  observe  distention  of  the  chest,  proportionate 
to  the  tension  of  the  air  or  gas  in  the  pleural  sac,  and  a  corresponding 
loss  of  motion. 

With  great  distention  there  will  be  no  motion  of  the  lower  ribs,  but 
prominence  of  the  spaces  between  them0 

Exceptional. — In  some  rare  cases  of  this  disease  the  upper  portion  of  the 
affected  side  seems  to  move  mere  than  the  corresponding  part  of  the  sound  side. 

This  is  due  to  the  extreme  efforts  on  inspiration  by  which  the  superior  ribs 
are  lifted  directly  upward  as  in  emphysema,  though  there  is  little  or  no  anterior 
expansion. 

HydrotTiorax  presents  a  condition,  on  both  sides,  similar  to  that 
found  in  pleurisy  with  effusion  upon  one  side;  hence  loss  of  motion  and 
more  or  less  bulging  of  the  infra-axillary  regions. 


14  '  PHYSICAL  DIAGNOSIS. 

Pericarditis,  if  the  amount  of  effusion  is  sufficient,  causes  considera- 
ble bulging  of  the  precordial  region,  especially  in  children;  but  in  older 
patients,  on  account  of  the  firmness  of  the  cartilages,  this  is  not  so  likely 
to  occur.  There  is  also  diminution  of  the  respiratory  movements  on 
the  left  side,  due  to  pressure  from  the  distended  pericardium. 

Cardiac  hypertrophy  also  occasions  local  bulging,  most  marked  in 
young  patients.  The  impulse,  if  visible,  will  be  seen  to  the  left,  below 
its  normal  position.     Its  area  will  also  be  increased. 

Tumors  within  the  thoracic  cavity  cause  bulging  when  of  sufficient 
size  to  press  upon  the  parietes.  If  the  tumor  be  aneurismal  or  solid  and 
rest  upon  a  large  artery,  it  will  usually  pulsate  synchronously  with  the 
contraction  of  the  heart.  An  enlarged  liver  or  spleen  may  occasion 
local  bulging. 

In  cases  of  pneumothorax  and  pleurisy  with  great  effusion,  we  ob- 
tain valuable  information  by  examining  the  impulse  caused  by  the  apex 
of  the  heart,  which  will  be  seen  crowded  from  its  normal  position  toward 
the  unaffected  side. 

In  membranous  croup,  oedema  glottidis,  foreign  bodies  or  morbid 
growths  in  the  larynx  or  in  the  trachea,  the  amount  of  air  entering  the 
lung  is  considerably  less  than  normal.  This  has  the  effect  of  prolong- 
ing inspiration  and  rendering  it  laborious,  though  expiration  is  not 
notably  affected.  Here  the  respiration  is  not  quickened  as  in  most  pul- 
monary diseases,  and  it  may  be  even  slower  than  usual.  This  differs 
from  emphysema  in  that  here  there  is  obstruction  to  inspiration;  in 
emphysema,  the  principal  interference  is  with  expiration. 

When  the  obstruction  in  the  larynx  or  trachea  is  considerable,  we 
observe  sinking  in  of  the  soft  parts  of  the  chest  above  the  clavicle  and  in 
the  intercostal  spaces,  especially  at  the  lower  part  of  the  chest,  during  in- 
spiration. This  is  due  to  atmospheric  pressure  from  without,  as  the 
chest  walls  expand  more  rapidly  than  air  can  enter  through  the  ob- 
structed passage  to  fill  the  lungs. 

In  chronic  bronchitis  the  signs  obtained  by  inspection  are  of  little 
value,  though  we  may  occasionally  observe  prolonged  expiration,  and 
in  some  instances  irregular  expansion  of  the  chest,  in  different  parts, 
due  to  plugging  of  the  bronchial  tubes  by  secretions. 

PALPATION. 

Palpation  consists  of  physical  exploration  by  the  sense  of  touch, 
either  with  the  tips  of  the  fingers  or  the  palms  of  the  hands. 

In  practising  palpation  upon  the  chest,  the  palmar  surface  of  the 
hands  should  be  used,  and  in  many  instances  it  is  desirable  to  cross  the 
hands  so  that,  as  one  sits  in  front  of  the  patient,  the  right  hand  rests 
upon  his  right  side  and  the  left  upon  his  left  side.  If  the  signs  are 
only  slight,  we  thus  appreciate  them  more  clearly. 


PALPATION.  15 

By  the  sense  of  touch  we  appreciate  slight  alterations  in  the  move- 
ments of  the  heart  and  thoracic  walls;  we  sometimes  detect  the  presence 
of  intra-thoracic  tumors  which  cause  no  bulging  of  the  surface,  and 
determine  their  nature,  whether  hard,  soft,  or  pulsating;  and  we  may 
differentiate  between  the  pain  of  intercostal  neuralgia  and  that  of 
pleurodynia  or  pleurisy. 

The  information  regarding  size,  form,  and  movements  obtainable  by 
this  method  is  essentially  the  same  as  that  furnished  by  inspection. 

Normal  vocal  fremitus  is  a  peculiar  vibration  which  will  be 
felt  if  the  hand  be  gently  placed  upon  the  chest  of  a  healthy  person 
while  he  is  speaking.  It  is  produced  by  the  transmission  to  the  chest 
wall  of  the  vibrations  of  air  in  the  bronchi,  caused  by  the  act  of  speak- 
ing. Modifications  of  vocal  fremitus  are  among  the  most  important 
signs  which  are  obtained  by  palpation. 

The  normal  vocal  fremitus  varies  in  different  individuals.  It  is  not 
usually  marked  in  women  and  children.  In  males  it  will  be  found  more 
or  less  defined  in  proportion  to  the  pitch  or  force  of  the  voice.  Voices 
of  low  pitch  cause  a  more  distinct  fremitus  than  those  which  are  higher. 
The  distinctness  of  this  sign  also  depends  upon  the  thickness  of  the 
chest  walls,  the  diameter  of  the  bronchi,  the  proximity  of  the  bronchi 
to  the  parietesj  and  the  distance  of  the  point  examined  from  the  larynx. 
It  is  therefore  more  marked  upon  the  right  than  upon  the  left  side, 
and  in  the  infra-clavicular  region  than  in  the  lower  part  of  the  chest. 

In  women,  this  sign  may  be  obtained  over  the  upper  portion  of 
the  chest,  but  is  seldom  found  over  the  lower  part.  In  men  it  is  usu^ 
ally  perceptible  over  the  whole  chest. 

Normal  vocal  fremitus  may  be  increased,  diminished,  or  abolished  by 
disease.  As  a  rule,  it  is  increased  by  all  diseases  causing  consolidation 
of  lung  tissue,  as  phthisis,  pneumonia,  oedema,  and  apoplexy  of  the  lungs. 
It  is  generally  increased  by  dilatation  of  the  bronchial  tubes,  in  which 
case  there  is  more  or  less  induration  of  the  parenchyma  of  the  lungs. 

Exceptional. — In  pneumonia,  when  the  bronchial  tubes  are  completely  filled 
by  the  inflammatory  deposit,  vocal  fremitus  cannot  be  felt. 

Owing  to  the  great  variation  of  this  sign  in  different  individuals  and 
to  its  mutations  in  disease  without  clearly  defined  causes,  it  is  not  of 
very  much  value  when  taken  alone. 

Vocal  fremitus  is  diminished  or  suppressed  by  any  disease  causing 
separation  of  the  lung  from  the  chest  wall  by  the  intervention  of  air, 
gas,  or  fluid.  In  pneumothorax,  hydrothorax,  and  pleurisy  with  effusion, 
absence  of  vocal  fremitus  over  the  air  or  the  fluid  is  a  sign  of  great  value. 

Exceptional. — Presence  of  vocal  fremitus  is  not  always  a  certain  sign  that 
fluid  does  not  exist,  as  snown  by  a  few  rare  cases.  If  there  is  but  a  small  col- 
lection of  air  or  fluid  in  the  pleural  sac,  vocal  fremitus  may  be  simply  diminished; 
and  in  multilocular  pleurisy  it  remains  over  the  bands  of  adhesion. 


16  PHYSICAL  DIAGNOSIS. 

In  emphysema,  vocal  fremitus  is  diminished. 

Aneurismal  or  other  intra-thoracic  tumors  cause  diminution  or  ab- 
sence of  vocal  fremitus  directly  over  them,  providing  no  lung  tissue  in- 
tervenes between  the  tumor  and  the  chest  wall.  » 

Vocal  fremitus  is  principally  of  value  in  differentiating  between  con- 
solidation of  lung  tissue  and  fluid  in  the  lower  part  of  the  chest.  When 
lung  tissue  is  consolidated,  fremitus  is  increased,  but  when  there  is  a  col- 
lection of  fluid,  it  is  absent.     Exceptions  to  this  rule  are  unimportant. 

Friction  fremiti's,  vibration  caused  by  rubbing  together  of  the 
roughened  surfaces  of  the  pericardium  or  pleura,  is  indicative  of  inflam- 
mation, with  exudation,  which  causes  roughening  of  the  serous  surface. 

Bronchial  or  rhoncal  fremitus  is  the  term  applied  in  acute  or 
chronic  bronchitis,  especially  in  children,  when  secretion  is  abundant, 
and  the  chest  walls  are  thrown  into  vibration  by  air  bubbling  through 
fluid  within  the  bronchi.  The  vibrations  communicate  to  the  hand  a 
distinct  bubbling  sensation,  which  cannot  be  mistaken. 

Fluctuation  of  fluid  within  the  pleural  cavity  may  often  be  felt  in 
the  intercostal  spaces  by  the  fingers  while  tapping  at  a  little  distance 
with  the  fingers  of  the  other  hand. 

MENSURATION. 

Mensuration  is  rarely  used,  since  inspection  and  palpation  give  suffi- 
ciently accurate  and  more  quickly  obtainable  knowledge  of  the  signs 
furnished.  Many  instruments  have  been  devised  for  determining  the 
size,  capacity,  and  degrees  of  curvature  or  flatness  of  the  chest.  The 
only  measurement  of  special  clinical  value  is  that  of  the  circumference, 
in  inspiration  and  in  expiration,  which  may  be  readily  taken  by  means 
of  a  simple  tape. 

A  good  device  for  this  consists  of  two  tapes  joined  at  their  extremi- 
ties and  so  padded  near  the  line  of  junction  as  to  form  a  sort  of  saddle, 
which  rests  upon  the  spinous  processes  and  prevents  slipping.  In  using 
this  instrument,  adjust  the  pads  to  the  spine  and  carry  the  tapes  about 
the  chest  on  both  sides  to  the  median  line  in  front.  The  exact  amount 
of  motion  of  the  two  sides  may  thus  be  easily  ascertained. 

In  measuring  with  a  single  tape,  place  the  thumb  nail  at  a  certain 
point  on  the  tape,  the  first  finger  about  one-fourth  of  an  inch  nearer  its 
end.  Then  press  the  tape  with  the  thumb  nail  against  the  middle  of  a 
spinous  process  and  press  the  forefinger  down  beside  it.  This  enables 
one  to  hold  the  tape  firmly  in  position,  and,  by  preventing  the  skin  from 
slidiug  in  respiration,  gives  a  fixed  point  from  which  to  measure.  It  is 
always  desirable  to  mark  the  median  line  in  front  before  commencing 
this  measurement. 

The  circumference  of  the  chest  may  be  taken  above  or  below  the 
nipples,  but  best  on  a  level  with  the  sixth  costo-sternal  articulation.  In 
recording  cases,  always  note  the  level  of  the  measurement. 


MENS  URA  TION. 


17 


The  measurement  should  be  taken  during  both  full  inspiration  and 
forced  expiration,  and  the  two  results  should  be  compared  to  determine 
the  expansion.  The  two  sides  must  be  compared  to  ascertain  whether 
either  is  distended  or  deficient  in  movement.  Quain  and  Carroll  in- 
vented very  satisfactory  instruments  for  taking  these  measurements, 
known  as  stethometers.  Quain's  instrument  (Fig.  4)  consists  of  a  cylin- 
drical box  with  a  dial  and  an  index,  moved  by  a  rack 
to  which  is  attached  a  cord  long  enough  to  compass 
the  chest.  Each  rotation  of  the  index  about  the 
dial  indicates  one  inch  of  movement.  The  box  is 
placed  upon  the  centre  of  the  chest  in  front,  and 
the  string  is  carried  horizontally  around 
the  chest;  as  the  patient  breathes,  the  f~^\ 

index  revolves  about  the  dial,  registering 
accurately   the   expansion   of  the  chest 
walls.     Carroll's  stethometer  is  simple  and  exact  (Fig.  5) 
a  simple  tape  is  sufficient. 

Measurements  of  the  healthy  chest,  of  course,  vary  in  different  indi- 
viduals. The  average  in  men  is  thirty-two  and  one  half  inches.  Gener- 
ally, the  right  side  exceeds  the  left  by  half  an  inch,  but  in  left-handed 
persons  the  reverse  is  true. 

In  disease,  the  affected  side  may  be  distended  or  contracted,  and  its 
movements  may  be  diminished  or  increased,  conditions  usually  noticea- 
ble on  inspection  and  by  palpation,  but  it  is  not  uncommon  to  find,  upon 
mensuration,  that  a  side  which  had  the  appearance  of  distention  is 


Fig   4.— Quain's  Stethometer. 


Ordinarily 


iy§_i 


Fig.  5. — Carroll's  Stethometer. 

smaller  than  its  fellow;  frequently  expansion,  which  has  seemed  com- 
paratively free,  will  be  found  by  the  tape  not  to  exceed  one-eighth  of  an 
inch. 

The  diseases  causing  expansion  or  contraction,  and  loss  of  move- 
ments of  the  chest  wails,  were  mentioned  under  inspection. 

The  transverse  diameter  of  the  chest  may  be  obtained  by  means  of  a 
pair  of  calipers,  or  by  Flint's  cyrtometer  (Fig.  6). 

Gee's  cyrtometer,  consisting  of  two  pieces  of  composition  gas-pipe 
joined  together  by  means  of  a  piece  of  rubber  tubing,  is  the  cheapest 
and  perhaps  the  best  instrument  for  ascertaining  the  transverse  outline 
of  the  chest.  In  using  it,  the  joint  is  placed  upon  the  spine,  and  the 
pieces  of  pipe  are  accurately  moulded  round  the  chest.     The  instrument 

2 


is  PHYSICAL  DIAGNOSIS.     - 

is  then  removed  and  laid  on  paper,  when  an  exact  tracing  can  be  made. 
In  a  well-formed  chest,  the  antero-posterior  diameter  will  be  to  the 
transverse  diameter  in  men  as  three  to  four,  in  women  as  four  to  five 
(Fig.  3).  Scott  Allison  invented  an  instrument,  known  as  a  stetho- 
goniometer,  for  measuring  the  curves  or  the  flatness  of  the  surface  of 


Fig.  6.— Flint's  Cyrtometer. 


Fig.  7. — Spirometer. 


the  chest  (Fig.  8).  It  has  been  claimed  that  the  infra-clavicular  space 
should  always  be  convex  in  health.  With  this  instrument  the  curva- 
tures could  be  accurately  ascertained,  but  unfortunately  the  information 
is  of  very  little  value,  because,  in  healthy  individuals,  this  region  is  often 
flat  or  even  concave. 

Spirometers  are  used  for  measuring  the  chest  capacity.     Hutchinson 
was,  I  think,  the  inventor  of  the  spirometer,  but  many  modifications 


Fig.  8.— Allison's  Stethogoniometer. 

have  been  devised.  Recently  portable  instruments  about  the  size  of  a 
watch  have  been  made.  In  one  of  these,  as  the  patient  inspires,  or 
blows  into  the  tube,  the  index  revolves  on  the  dial,  registering  the  num- 
ber of  cubic  inches  of  air  inhaled  or  expired. 

Hutchinson  found  that  people  five  feet  in  height  usually  possess  a 
vital  capacity  of  one  hundred  and  seventy-four  cubic  inches,  and  for 
every  inch  of  height  above  five  feet,  eight  cubic  inches  should  be  added 


MENSURATION. 


19 


to  the  healthy  standard.  There  are  many  obstacles  to  the  use  of  spiro- 
meters rendering  them  practically  useless.  For  instance,  it  takes  most 
persons  some  time  to  learn  how  to  blow  into  one  of  these  instruments. 
A  patient  may  at  one  time  expire  only  one  hundred  and  fifty  cubic 


Fig.  9.— Hammond's  HjEMadynamometer. 

inches,  and  at  another,  without  any  change  of  health,  two  hundred  cubic 
inches.  Furthermore,  women  and  men,  the  young  and  the  old,  all  have 
different  vital  capacities,  and  it  has  not  yet  been  possible  to  arrive  at 
an  accurate  healthy  standard. 

Hammond  devised  the  hsemadynamometer,  which  he  used  for  meas- 
uring the  force  of  inspiration  and  expiration.     He  found  that  individ- 


20  PHYSICAL  DIAGNOSIS. 

uals  five  feet  eight  inches  in  height  possess  the  maximum  respiratory 
power.  His  instrument  (Fig.  0)  consists  of  a  bent  glass  tube  fastened 
to  a  graduated  scale,  and  joined  at  each  end  by  a  rubber  tube,  through 
which  the  patient  is  to  breathe.  The  instrument  is  partially  filled  with 
mercury,  which  rises  on  one  side  or  the  other  as  the  patient  inspires  or 
expires  through  the  mouth-piece  and  falls  after  he  ceases. 

Hammond  found  the  expiratory  power  much  greater  than  the 
inspiratory,  the  average  man  being  able  to  raise  the  column  of  mercury 
three  inches  by  expiration,  and  only  two  by  inspiration.  This  is  a  fact 
which  at  once  explains  some  of  the  phenomena  of  disease.  For  instance, 
Laennec's  hypothesis  as  to  the  cause  of  pulmonary  emphysema  was  based 
upon  the  supposition  that  the  inspiratory  power  was  greater  than  the 
expiratory,  a  supposition  clearly  untenable  after  Hammond's  demon- 
stration. 

SUCCUSSION. 

Succussion,  the  fourth  method  of  physical  exploration,  was  known  to 
Hippocrates.  It  consists  of  suddenly  shaking  the  patient's  body  while 
the  ear  is  placed  against  his  chest. 

When  air  and  fluid  occupy  the  pleural  sac,  this  proceeding  will  cause 
a  splashing  sound.  The  sign  is  of  value  in  pneumo-hydrothorax  (Fig. 
26).  The  succussion  sound  will  vary  more  or  less  in  quality  with  the 
density  of  the  fluid.  Thick  pus  will  not  yield  the  same  sound  as  thin 
serum,  but  the  quality  of  these  sounds  is  not  usually  sufficiently  distinc- 
tive to  aid  us  materially  in  our  diagnosis. 

Metallic  tinkling,  due  to  dropping  of  fluid  from  the  upper  part  of 
the  cavity  into  the  effusion  below,  can  usually  be  heard  when  the  succus- 
sioD  signs  are  present  (Fig.  26). 


CHAPTER  II. 

METHODS   OF  EXAMINATION.— Continued. 

PERCUSSION. 

PERCUSSION"    IN    HEALTH. 

Percussion  is  the  art  of  eliciting  sound  by  striking  with  the  fingers, 
•or  with  instruments  constructed  for  the  purpose. 

As  a  means  of  diagnosis,  it  is  generally  supposed  to  have  originated 
during  the  last  century  with  Avenbrugger,  a  physician  of  Vienna,  bat 
the  works  of  Hippocrates  indicate  that  he  was  familiar  with  it,  to  a 
limited  extent. 

Hippocrates  and  Avenbrugger  recommended  immediate  percussion. 
in  which  the  blow  is  struck  directly  upon  the  chest  wall. 


Fig.  10.— Flint's  Hammer  and  Pleximeter. 

This  form  of  percussion  has  been  nearly  supplanted  by  one  which 
originated  about  sixty  years  ago,  with  M.  Piorry,  termed  mediate  percus- 
sion, in  which  the  blow  is  received  on  some  intervening  substance. 

Before  mediate  permission  was  employed,  it  was  quite  essential  to  intensify 
the  sounds  ;  this  was  accomplished  by  placing  the  patient  with  his  back  against 
a  hollow  wall.  In  some  women  the  signs  elicited  by  immediate  percussion  are 
quite  distinct  over  the  upper  part  of  the  chest,  but  usually  this  method  is  very 
unsatisfactory. 

In  mediate  percussion,  a  small  hammer  or  plexor  and  an  instrument 
known  as  a  pleximeter  or  plessimeter  are  employed.  The  hammer  in 
common  use  consists  of  a  cylindrical  rubber  head  attached  to  a  light 
handle  about  eight  inches  in  length.  Metallic  hammers  faced  with 
rubber,  as  sometimes  used,  are  objectionable  on  account  of  their  weight, 
which  renders  the  blow  so  forcible  that  it  is  apt  to  cause  pain. 


22  PHYSICAL  DIAGNOSIS. 

Pleximeters  are  made  of  various  materials,  as  rubber,  bone,  wood, 
ivory,  or  leather.  Some  of  them  are  graduated  in  order  that  they  may 
be  used  in  mensuration.  Among  the  best  is  one  which  consists  of 
a  narrow  oval  disc  of  hard  rubber,  with  large  ears  at  each  extremity. 

It  should  be  narrow  enough  to  be  placed  between  the  ribs,  and  should  have 
a  large  projection  at  each  end,  that  it  may  be  firmly  graced.  I  have  frequently 
used  a  small  cylinder  of  soft  rubber  about  two  inches  long  and  half  an  inch  in 
diameter.  It  lias  the  advantage  of  being  easily  adapted  to  the  intercostal  spaces, 
and  of  emitting  no  sounds  of  its  own  -when  struck. 

For  ordinary  percussion  it  is  best  to  use  the  middle  or  index  finger 
of  one  hand  in  place  of  the  pleximeter,  and  two  or  three  fingers  of  the 
other,  with  their  tips  brought  into  line,  as  a  hammer.  The  fingers  used 
as  a  plexor  should  be  brought  as  nearly  as  possible  to  a  right  angle  at 
the  second  joint,  that  the  terminal  phalanges  may  strike  perpendicularly 
upon  the  finger  of  the  opposite  hand. 

When  the  fingers  are  used,  there  is  noticeable  a  certain  sense  of 
resistance  which  is  not  obtained  with  instruments.  Often  this  would 
enable  us  to  detect  internal  organic  changes  even  with  our  ears  com- 
pletely stopped.  So  valuable  is  it  in  intricate  cases  that,  when  there  is 
difficulty  in  making  an  accurate  diagnosis,  I  always  employ  the  fingers 
instead  of  instruments  for  percussion. 

The  sounds  obtained  by  percussion  are  generally  described  as  clear, 
dull,  and  tympanitic,  but  these  terms  are  not  sufficiently  precise  to  aid 
us  much  in  studying  the  method.  I  prefer  a  classification  based  upon 
acoustic  properties.  The  elements  of  sound  which  concern  us  in  per- 
cussion are  intensity,  pitch,  quality,  and  duration. 

The  intensity  of  a  sound  determines  the  distance  at  which  the 
sound  maybe  heard.  Other  things  being  equal,  the  intensity  of  a  sound 
in  pulmonary  percussion  varies  with  the  force  of  the  blow,  the  volume 
of  air  in  the  lung,  and  the  thickness  and  elasticity  of  the  chest  walls. 
It  is  diminished  by  thick  layers  of  fat  or  muscle,  by  rigidity  of  the  costal 
cartilages,  and  by  contraction  or  consolidation  of  the  lung,  and  it  is  in- 
creased by  the  opposite  conditions. 

The  pitch  of  a  percussion  sound  may  be  high  or  low.  Those  famil- 
iar with  music  will  understand  this,  but  a  common  mistake  is  to  con- 
found pitch  with  intensity.  Many  students  suppose  that  the  higher  the 
pitch,  the  greater  the  intensity.  The  reverse  of  this  is  usually  true  in 
pulmonary  percussion,  intense  sounds  being  low  pitched,  and  high- 
pitched  sounds  possessing  feeble  intensity. 

This  difference  between  pitch  and  intensity  can  be  easily  recognized  by 
striking  two  notes  at  opposite  ends  of  the  keyboard  of  a  piano.  By  striking  a 
high  note  forcibly,  one  will  obtain  a  sound  loud  enough  to  be  heard  some  dis- 
tance ;  then  by  gently  tapping  a  key  at  the  other  end,  one  will  obtain  a  sound 
heard  at  exactly  the  same  distance,  but  of  a  much  lower  pitch. 

The  pitch  of  the  percussion  note  over  a  healthy  lung  is  always  low, 


PERCUSSION.  23 

but  it  will  vary  in  different  portions  of  the  chest,  owing  to  difference  in 
the  volume  of  air  and  the  position  of  other  intra-thoracic  organs. 

Quality  of  sound  is  that  element  by  which  we  distinguish  between 
the  tones  of  musical  instruments,  or  of  voices  of  different  individuals, 
having,  it  may  be,  the  same  intensity  and  pitch. 

In  pulmonary  percussion,  we  obtain  a  peculiar  quality  termed  vesic- 
ular, impossible  to  describe,  but  always  to  be  obtained  by  percussion  of 
the  healthy  chest.  It  is  soft  and  low  in  pitch,  and  usually  seems  as 
though  coming  from  a  point  a  couple  of  inches  beneath  the  surface.  It 
can  be  learned  only  by  studying  the  healthy  chest. 

Dttratiox  of  the  healthy  percussion  note  depends  upon  the  same 
causes  as  its  pitch.  If  its  pitch  is  high,  the  duration  is  short;  if  the 
pitch  is  low,  the  duration  is  prolonged.  Indeed,  a  definite  relation  exists 
between  all  these  different  elements;  that  is,  intense  sounds  are  apt  to 
be  low  pitched;  those  which  are  feeble  are  generally  short  and  high 
pitched,  and,  instead  of  the  vesicular,  they  possess  a  solid  character. 

Percussion  seems  very  simple  as  practised  by  an  adept,  but  accuracy 
is  not  acquired  without  much  practice. 

Certain  rules  essential  to  accurate  percussion  should  be  early  fixed  in 
mind. 

The  surface  of  the  chest  should  be  bare;  but  if  for  any  reason  this 
cannot  be  secured,  have  the  covering  soft,  thin,  and  smooth.  It  is  abso- 
lutely useless  to  percuss  the  chest  of  a  patient  who  has  on  one  or  two 
shirts  and  perhaps  a  chest  protector  or  corset. 

The  patient  should  be  in  a  comfortable  position,  whether  sitting, 
standing,  or  lying  upon  the  back,  and  the  two  sides  must  be  relatively 
symmetrical.  The  first  two  positions  are .  preferable,  but  very  sick  pa- 
tients should  not  rise  for  the  examination;  it  will  be  better  to  make  a 
less  critical  examination  than  to  endanger  the  patient. 

Persons  suffering'  from  diseases  which  cause  feebleness  of  the  heart  should 
not  be  asked  to  sit  or  stand.  Illustrating  the  importance  of  this  caution,  I  have 
seen  cases  of  sudden  death  from  overtaxing  of  a  weak  heart,  by  slight  exertion, 
such  as  the  getting  out  of  bed  of  a  patient  convalescing  from  pneumonia  or 
diphtheria. 

Do  not  allow  the  patient  to  twist  the  body  or  move  the  arms  during 
percussion,  as  such  motions  change  the  relations  of  the  muscles,  and 
thus  alter  the  percussion  note. 

The  physician's  ear  should  be  squarely  in  front  of  the  part  percussed. 
If  he  stand  partially  to  one  side,  the  signs  obtained  on  that  side,  even 
though  the  same  as  those  on  the  other,  will  reach  the  ear  with  a  different 
tone.  His  position  should  be  easy  and  unrestrained,  or  he  will  not- 
recognize  slight  differences  in  sound. 

In  percussing  any  particular  region  of  the  chest,  aim  to  have  the 
chest  walls  as  thin  and  tense  as  possible.  To  secure  this  on  the  anterior 
portions  of  the  chest,  the  arms  should  hang  at  the  sides  and  the  shoulders 


2i  PHYSICAL   DIAGNOSIS. 

should  be  thrown  backward.  In  examining  the  lateral  region.-,  it  is  well 
to  have  the  hands  rest  upon  the  head.  If  the  arms  are  held  up,  the 
muscles  stand  out  so  prominently  that  they  interfere  with  obtaining  the 
pulmonary  resonance.  In  percussing  the  posterior  regions,  the  trunk 
should  be  bent  forward  and  the  arms  crossed  in  front. 

In  percussing  the  chest,  compare  corresponding  portions  of  the  two 
sides.  If  changes  from  the  normal  are  slight,  they  can  be  detected  in 
no  other  way.  Ordinarily  it  is  sufficient  to  repeat  a  series  of  strokes  first 
on  one  side,  then  on  the  other,  or  to  percuss  both  sides  repeatedly  in 
quick  succession.  However,  the  percussion  sounds  vary  slightly  at  dif- 
ferent periods  of  the  act  of  respiration  ;  therefore,  whenever  the 
changes  are  so  slight  as  to  require  great  care  for  their  discrimination, 
the  sides  should  be  compared  during  the  same  stage  of  the  respiratory 
act.  The  best  period  at  which  to  make  the  comparison  is  at  the  close 
of  a  forced  expiration. 

Exceptional. — In  health  the  two  sides  are  not  always  alike  as  regards  dis- 
parity between  the  note  elicited  in  full  inspiration  and  that  elicited  in  forced  ex- 
piration. 

In  applying  the  finger  or  the  pleximeter,  be  careful  that  it  presses 
evenly  upon  the  surface  and  displaces  all  the  air  beneath  it.  Otherwise, 
the  resonance  of  the  pleximeter  is  obtained  instead  of  that  from  the 
chest,  and  at  the  same  time  the  air  is  suddenly  forced  out,  causing  a 
sound  very  similar  to  cracked-pot  resonance. 

The  force  of  the  stroke  should  be  moderate,  never  great  enough  to 
cause  the  patient  pain,  and  alike  on  both  sides.  In  percussing  super- 
ficial portions  of  the  lung,  the  stroke  should  lie  very  gentle,  but  to 
obtain  the  resonance  from  deeper  parts  it  must  be  more  forcible.  Be- 
ginners commonly  strike  much  too  hard. 

The  stroke  should  be  from  the  wrist  alone,  whether  made  with  the 
hammer  or  with  the  finger.  When  striking  from  the  elbow,  we  cannot 
control  the  force  of  the  blow.  Some  diagnosticians  are  accustomed  to 
strike  a  single  blow,  first  upon  one  side,  then  upon  the  other:  but  I  get 
better  results  by  making  three  or  four  taps  in  rapid  succession. 

The  direction  of  the  stroke  should  always  be  perpendicular  to  the 
surface  of  the  chest.  If  we  percuss  obliquely,  instead  of  obtaining  the 
resonance  from  the  lung  immediately  beneath  the  pleximeter,  we  get 
that  from  a  rib  or  from  more  distant  tissue. 

In  percussing  near  i-he  sternum,  in  the  tipper  portion  of  the  chest, 
We  obtain  resonance  from  the  trachea  instead  of  from  the  lung,  unless 
care  be  taken  to  direct  the  blow  toward  the  central  portion  of  the  apex. 

The  stroke  should  be  a  simple  tap,  the  finger  or  hammer  being  al- 
lowed to  rebound  instantly,  instead  of  resting  a  moment  on  the  plexi- 
meter, which  has  an  effect  on  pulmonary  resonance  similar  to  that  pro- 
duced by  touching  a  vibrating  tuning-fork.  In  percussing  with  the 
fingers,  strike  with  their  tips,  instead  of  with  the  pulps. 


PERCUSSION.  25 

As  the  signs  in  a  healthy  chest  vary  in  its  different  regions,  we 
must  take  special  pains  to  familiarize  ourselves  with  all  the  healthy 
sounds.  There  are  no  two  healthy  people  whose  chests  are  exactly 
alike,  therefore  we  can  take  no  one  person  as  a  standard  for  compari- 
son; but  after  percussing  many  healthy  chests,  we  may  form  an  ideal 
standard  from  which  no  great  variation  can  occur  without  indicating 
disease. 

Normal  vesicular  resonance  is  obtained  most  perfectly  in  the  left 
infra-clavicular  region;  and  this,  being  the  sound  obtained  over  the  pul- 
monary air  vesicles,  is  taken  as  the  standard  for  comparison  in  pulmo- 
nary percussion. 

In  the  right  infra-clavicular  region  the  percussion  note  is  nearly  the 
same  as  in  the  left,  but  is  slightly  harder  or  more  tubular  in  quality, 
owing,  probably,  to  the  greater  size  of  the  bronchial  tubes. 

In  the  middle  of  the  supra-clavicular  region  the  resonance  is  soft  or 
vesicular  in  quality,  but  toward  the  inner  part  of  this  region  it  becomes 
harder  in  quality  or  tubular  and  higher  in  pitch.  Austin  Flint  called 
this  an  approach  to  tympanitic  resonance.  Externally  in  this  region 
the  vesicular  quality  is  diminished.  In  percussing  over  the  central  por- 
tion of  the  clavicular  region,  the  sound  is  fairly  vesicular,  but  it  becomes 
less  and  less  so  toward  either  end  of  the  clavicle. 

In  the  mammary  regions  the  sounds  are  altered  on  one  side  by  the 
presence  of  the  heart,  and  on  the  other  side  by  the  presence  of  the  liver 
(Fig.  1).  In  the  upper  part  of  the  right  mammary  region  we  obtain 
vesicular  resonance  extending  down  to  the  line  of  hepatic  dulness  in 
the  fourth  interspace.  Below  this,  where  the  lung  overlaps  the  liver, 
dulness  is  appreciable  on  forcible  percussion,  gradually  becoming  more 
and  more  distinct  as  the  lung  decreases  in  thickness,  until  we  reach  the 
lower  border  of  the  lung  at  the  sixth  rib,  the  line  of  hepatic  flatness, 
below  which  we  lose  all  pulmonary  resonance. 

The  lines  of  hepatic  dulness  and  of  hepatic  flatness,  the  first  along 
the  upper  margin  of  the  liver,  the  second  at  the  lower  margin  of  the 
lung,  are  ordinarily  about  two  inches  apart. 

Exceptional. — In  deep  inspiration  the  lower  line  may  be  carried  an  inch  and 
a  half  or  two  inches  lower,  and  in  forcible  expiration  it  may  be  elevated  from  one 
to  live  inches  ;  therefore  the  area  of  hepatic  dulness,  between  the  two  lines,  may 
vary  from  two  to  seven  or  even  eight  inches.  This  wide  range  is  not  common, 
but  its  occasional  occurrence  shows  the  necessity  for  studying-  the  chest  in  both 
inspiration  and  expiration. 

In  the  left  mammary  region  pulmonary  resonance  exists  over  the 
outer  part.  Near  the  middle  of  the  region  forcible  percussion  elicits 
cardiac  dulness.  Near  the  sternum  the  heart  is  superficial,  covered  only 
by  the  pericardium  and  by  cellular  tissue;  here  there  is  a  small,  triangu- 
lar space  yielding  flatness.  It  is  about  an  inch  and  a  half  wide  at  its 
base,  which  corresponds  to  the  sixth  rib,  and  extends  from  the  fourth 


26  PHYSICAL  DIAGNOSIS. 

to  the  sixth  costal  cartilage.  The  apex  of  this  triangle  is  located  at  the 
margin  of  the  sternum  on  a  level  with  the  fourth  rib. 

The  resonance  of  the  mammary  region  is  modified  more  or  less  by 
the  thickness  of  the  muscles  in  men  and  by  the  mammary  glands  in 
women. 

In  the  infra-mammary  region,  on  the  right  side  usually,  there  is 
nothing  but  the  liver  to  affect  the  percussion  note,  hence  we  have  a 
sound  termed  flatness,  like  that  obtained  by  percussing  the  thigh.  If 
the  colon  be  distended  by  gas,  we  obtain  tympanitic  resonance  in  the 
lower  part  of  this  region. 

In  the  left  infra-mammary  region  flatness  caused  by  the  left  lobe  of 
the  liver  extends  a  couple  of  inches  to  the  left  of  the  median  line.  In 
the  outer  portion  of  this  region  we  obtain  a  similar  sound  from  the 
spleen,  and  between  these  two  organs  we  elicit  tympanitic  resonance 
from  the  stomach. 

In  the  upper  sternal  region,  as  low  as  the  level  of  the  second  costal 
cartilage,  the  sound  is  tubular,  or,  according  to  Flint,  tympanitic. 
This  is  due  to  the  presence  of  the  trachea,  the  sounds  of  which  are 
modified  by  the  anterior  borders  of  the  lungs  which  are  in  apposition 
throughout  this  region.  Below  the  level  of  the  second  ribs,  on  light 
percussion,  pulmonary  resonance  may  be  heard,  though  modified  by  the 
timbre  of  the  bone.  But  deep  percussion  gives  dulness,  resulting  from 
the  presence  of  the  great  blood-vessels. 

Over  the  lower  sternal  region,  by  light  percussion,  pulmonary  reso- 
nance is  obtained  to  the  right  of  the  median  line,  while  on  forcible  per- 
cussion there  is  dulness.  Left  of  the  median  line,  the  heart  is  super- 
ficial and  yields  flatness.  At  the  inferior  portion  of  this  region,  flatness 
is  due  to  the  left  lobe  of  the  liver. 

Over  the  scapula,  the  vesicular  sound  is  indistinct  from  the  thick- 
ness of  the  muscular  tissue,  but  above  the  spine  of  the  scapula  it  is 
much  more  marked  than  below,  and  in  the  upper  part  of  this  region  it 
is  quite  clear. 

In  the  inter-scapular  regions  the  sounds  are  hard  in  quality  and 
high  pitched,  because  the  chest  walls  are  thick.  There  is,  however,  in 
all  cases  some  pulmonary  resonance.  The  pitch  is  a  trifle  higher  on  the 
left  side  on  account  of  the  aorta. 

In  the  infra-scapular  regions  the  vesicular  resonance  is  well  defined, 
though  not  quite  so  clear  as  in  the  infra-clavicular  region.  It  extends 
downward  to  the  tenth  or  eleventh  rib.  On  the  right  side  we  find  the 
line  of  hepatic  dulness  at  the  eighth  rib  and  the  line  of  hepatic  flatness 
at  the  eleventh  rib;  but  these  vary  from  one  to  two  inches  during  forci- 
ble respiration  (Fig.  2). 

On  the  left  side  the  resonance  is  slightly  modified  near  the  spine  by 
the  nearness  of  the  liver.  Below  the  tenth  rib  the  intestinal  canal,  if 
filled  with  gas,  causes  a  tympanitic  sound.     In  the  outer  part  of  this 


PERCUSSION.  21 

region,  between  the  ninth  and  eleventh  ribs,  d illness  is  obtained  over 
the  spleen,  and  for  a  short  distance  abont  this  dnll  region  resonance  is 
rendered  more  or  less  tympanitic  by  the  stomach  and  intestines.  In  the 
lower  part  of  the  left  infra-scapular  region,  close  to  the  spinal  column, 
dulness  is  found  over  the  kidney,  and  it  occurs  in  a  similar  position, 
though  a  trifle  lower,  on  the  right  side. 

In  the  axillary  regions  the  resonance  is  often  more  marked  than  in 
the  infra-clavicular. 

In  the  infra-axillary  region  the  resonance  is  modified  on  the  right 
side  by  the  liver,  and  upon  the  left  by  the  stomach  and  spleen. 

In  this  region  the  margin  of  the  lung  passes  obliquely  downward 
and  backward  from  the  anterior  boundary  near  the  sixth  rib  to  the  pos- 
terior near  the  tenth  rib.  On  the  right  side,  hepatic  flatness  is  found 
below  this  line,  and  hepatic  dulness  a  couple  of  inches  higher.  On  the 
left  side,  below  this  line,  we  find  tympanitic  resonance  in  front  over  the 
stomach,  and  dulness  posteriorly  over  the  spleen.  In  this  locality  the 
pulmonary  resonance  is  often  modified  by  the  stomach,  as  high  as  the 
fourth  rib. 

The  size  of  the  spleen  varies  considerably,  even  in  health.  The  area  of 
dulness  which  it  causes  seldom  exceeds  two  and  one-half  inches  in  height 
by  about  four  inches  in  width;  about  half  of  this  dull  space  is  in  the 
infra-scapular  and  half  in  the  infra-axillary  region. 

Exceptional. — In  rare  cases  the  spleen  rises  as  high  as  the  lower  boundary  of 
the  axillary  region,  or  the  stomach  may  yield  decided  tympanitic  resonance  as 
high  as  the  fourth  rib. 

In  the  infra-scapular  region,  upon  the  right  side  in  children,  dulness  is  some, 
times  very  pronounced,  due  to  the  disproportionate  size  of  the  liver  in  early  life. 
This  is  not  infrequently  mistaken  for  the  consolidation  of  pneumonia. 

The  percussion  sounds  in  different  regions  of  the  chest  are  modified 
by  age,  sex,  and  various  idiosyncrasies.  In  old  age,  the  chest  walls  are 
less  elastic  than  in  middle  life,  and  the  lung  has  undergone  some  change 
which  renders  the  sounds  harder  in  quality  and  higher  in  pitch.  In 
children,  the  lungs  are  very  resonant,  and  the  costal  cartilages  are  elas- 
tic; consequently  we  obtain  a  low-pitched,  intense  vesicular  sound.  In 
men  the  percussion  note  over  the  upper  portion  of  the  chest  is  not 
usually  so  resonant  as  in  women,  but  it  is  more  distinct  over  the  lower 
portions.  It  will  be  seen,  from  what  has  already  been  said,  that  there  is 
notable  dissimilarity  of  the  percussion  sounds  on  the  two  sides  in  the 
mammary  regions,  as  also  in  the  infra-mammary,  infra-axillary,  and 
infra-scapular  regions.  In  all  other  portions  of  the  chest  the  resonance 
is  nearly  identical  on  the  two  sides,  but  the  slight  normal  disparity  in 
the  infra-clavicular  regions  is  a  point  of  great  importance. 


PHYSICAL  DIAGNOSIS. 
PERCUSSION    IN    DISEASE. 

In  disease,  the  percussion  sounds  may  occur  in  every  gradation  from 
normal  to  tympanitic  resonance  or  flatness.  These  varieties  have  heen 
variously  classified.  R.  E.  Thompson  classifies  them  as  clear,  dull,  tym- 
panitic, amphoric,  and  cracked-pot  resonance.  Flint  arranged  them 
under  six  heads;  and  A.  L.  Loomis  under  seven, as  follows:  Exaggerated 
pulmonary  resonance,  dulness,  flatness,  tympanitic  resonance,  vesiculo- 
tympanitic resonance,  amphoric  resonance,  and  cracked-pot  resonance, 
or  the  cracked-metal  sound. 

Exaggerated  pulmonary  resonance  differs  from  the  normal 
vesicular  sound  only  in  its  intensity.  The  pitch  and  quality  are  the 
same  as  in  health,  but  the  intensity  is  increased.  This  sound  is  obtained 
over  lung  tissue  which  is  receiving  more  air  than  usual,  and  which  might 
therefore  be  said  to  be  in  the  highest  degree  of  health. 

The  sign  is  therefore  only  negative,  as  it  is  indicative  of  no  disease 
whatever  in  the  place  where  it  is  obtained,  but  rather  points  to  deficient 
action  in  some  other  part  of  the  respiratory  tract.  Exaggerated  pul- 
monary resonance,  in  adults,  is  very  nearly  the  same  as  the  normal  reso- 
nance in  children.  The  sign  results  from  obstruction  to  the  entrance  of 
air  into  some  portion  of  the  respiratory  tract,  whether  from  filling  up 
of  the  air  cells  by  inflammatory  exudation  as  in  pneumonia,  from  nar- 
rowing of  the  bronchial  tubes,  or  from  collapse  of  the  air  cells.  Pneu- 
monia of  one  lung  or  of  a  single  lobe  of  a  lung  causes  exaggerated 
resonance  over  healthy  portions  of  the  lungs.  Compression  of  the  lung 
from  air  or  fluid  in  the  pleural  sac  gives  rise  to  exaggerated  resonance 
on  the  sound  side.  If  one  main  bronchus  is  occluded,  from  causes 
within  it  or  external  to  it,  resonance  is  exaggerated  on  the  opposite  side. 
In  extreme  anaemia  exaggerated  resonance  occurs  on  both  sides,  due 
probably  to  a  diminished  amount  of  blood  in  the  pulmonary  circuit.  As 
the  chest  is  practically  a  cavity  with  unyielding  walls,  diminution  in  its 
fluid  contents  must  cause  a  corresponding  increase  in  the  amount  of  air. 

Dulness  indicates  a  small  amount  of  air  beneath  the  part  percussed. 
It  can  always  lie  obtained  in  the  healthy  chest  where  the  lung  overlaps 
the  liver.  This  sign  differs  from  normal  vesicular  resonauce  in  having 
nigh  pitch,  hard  quality,  and  comparatively  short  duration.  Its  inten- 
sity is  usually  less  than  that  of  vesicular  resonance.  Varying  degrees  of 
dulness  should  be  carefully  studied  on  the  healthy  chest.  Over  the 
liver,  on  forcible  percussion,  slight  dulness  is  found  in  the  fourth  inter- 
costal space,  becoming  more  distinct,  higher  in  pitch,  harder  in  quality, 
and  shorter  in  duration,  as  examination  extends  downward,  toward  the 
lower  margin  of  the  lung. 

This  sign,  when  obtained  in  a  position  which  should  yield  vesicular 
resonance,  indicates  that  something  has  occurred  to  diminish  the  nor- 
mal amount  of  air  in  that  part  of  the  lung.     It  is  obtained  over  consolir 


PERCUSSION  IN  DISEASE.  29 

dated  lung,  from  simple  inflammation  or  from  phthisis,  from  com- 
pression of  the  lung  or  from  collapse  of  the  air  cells ;  over  collections 
of  fluid  in  the  bronchi  or  in  the  air  vesicles;  over  moderate  exudations 
in  the  pleural  sac  separating  the  lung  from  the  chest  trails,  but  effusions 
of  any  considerable  amount  destroy  pulmonary  resonance  entirely,  giving 
flatness.  Dulness  is  also  obtained  over  intra-thoracic  tumors,  whether 
solid  or  fluid,  provided  a  small  portion  of  lung  tissue  containing  air 
intervenes  between  them  and  the  thoracic  wall.  It  is  one  of  the  signs 
found  in  pneumonia,  pleuritis,  phthisis,  atelectasis,  and  in  intra-thoracic 
abscesses,  aneurisms,  and  tumors. 

Exceptional. — Dulness  results  occasionally  from  pulmonaiy  apoplexy.  In 
such  cases  it  is  usually  found  at  the  lower  angle  of  the  scapula.  It  may  arise 
from  brown  induration  of  the  lung,  due  to  a  varicose  condition  of  the  pulmonary 
veins.  In  this  disease  it  is  found  near  the  middle  of  the  lungs  on  both  sides. 
It  may  arise  from  enlarged  bronchial  glands,  and  in  a  few  instances  it  is 
found  in  bronchitis  over  the  apex  of  the  lungs,  or  more  clearly  at  the  lower  pos- 
terior part  of  the  chest,  due  to  a  collection  of  secretions  within  the  bronchi. 

Flatness  differs  from  dulness  in  complete  absence  of  vesicular  res- 
onance. Dulness  indicates  that  there  is  some  air  beneath  the  point  at 
which  the  stroke  is  made;  flatness,  that  there  is  none.  Dulness  is  ob- 
tained over  that  portion  of  the  liver  overlapped  by  lung  tissue;  flatness 
over  that  portion  below  the  sixth  rib,  which  is  superficial.  Dulness 
occurs  in  pleurisy  where  the  exudation  has  separated  the  lung  a  short 
distance  from  the  chest  wall  and  caused  a  corresponding  diminution  in 
the  volume  of  air.  Flatness  will  be  found  in  the  same  disease,  when  an 
effusion  of  serum  lifts  the  lung  above  it,  removing  all  air- containing 
tissue  from  beneath  the  point  percussed. 

Flatness  is  found  in  pleurisy  with  effusion  oftener  than  in  any  other 
disease. 

Exceptional. — In  rare  cases  of  pneumonia  the  inflammation  runs  to  such  a 
height  that  not  only  the  air  cells,  but  also  the  bronchial  tubes  are  filled  with  the 
exudation,  and  in  such  cases  absolute  flatness  is  found  over  the  lung  tissue. 
Again,  when  the  lung-  becomes  completely  collapsed  from  pressure  or  obstruc- 
tion of  a  large  bronchus,  flatness  results. 

Tumors  or  abscesses  within  the  thorax,  when  they  rest  against  the 
chest  walls,  cause  flatness. 

Tympanitic  kesoxaxce  is  the  name  given  to  the  sound  which  may 
be  normally  obtained  over  the  stomach  or  the  intestines  when  filled  with 
air  or  gas.  It  indicates  a  quantity  of  air  enclosed  by  walls  thin  and  yield- 
ing and  not  too  tense  (Da  Costa). 

Under  certain  conditions,  this  sign  is  met  with  over  the  thorax. 
Tympanitic  resonance  is  usually  described  as  of  higher  pitch  than  the 
vesicular  sound.  Its  duration  may  be  longer  or  shorter,  and  its  quality 
is  hollow,  conveying  the  idea  of  more  or  less  tension;  it  is  also  some- 
what  hard,   metallic,   and   ringing.      Statements   of   different   authors 


30  PHYSICAL  DIAGNOSIS. 

Conflict  concerning  the  pitch  of  this  sign.     Some  hold  that  it  is  high, 
Others  that  it  is  low. 

It  seems  to  me  that  the  discrepancy  has  arisen  from  mistaking  the  ringing 
metallic  quality  of  the  sound  for  a  high  pitch,  when  it  may  really  be  low.  I  find 
the  weight  of  opinion  in  favor  of  a  high  pitch.  R.  E.  Thompson,  in  his  little 
work  on  physical  examination  of  the  chest,  states  that  the  pitch  of  this  sign  may 
be  either  high  or  low  :  high  when  the  tension  of  the  volume  of  air  is  great,  and 
low  when  it  is  slight. 

This  variety  of  resonance  is  never  found  in  the  healthy  chest,  unless 
it  he  transmitted  from  some  of  the  organs  beneath  the  diaphragm;  it  is 
frequently  obtained  below  the  fourth  rib,  on  the  left  side  from  gaseous 
distention  of  the  stomach  or  the  intestines  and  occasionally  over  the 
infra-mammary  region  on  the  right  side  when  the  colon  is  distended. 
When  obtained  over  portions  of  the  chest  which  should  yield  a  vesicular 
Bound,  the  sign  usually  indicates  a  collection  of  air  or  gas  in  the  pleural 
sac,  as  in  pneumothorax.  Occasionally  it  is  found  over  a  large  cavity 
in  the  lung  tissue  containing  air. 

"  Pulmonary  cavities  are  generally  produced  by  jihthisis;  hence  the 
rule,  that  there  are  only  two  diseases  of  the  chest,  pneumothorax  and 
phthisis,  in  which  this  sign  is  found. 

Exceptional. — Guttman,  Gee,  and  some  others  claim  that  this  variety  of 
'resonance  sometimes  results  from  diminished  tension  of  the  pulmonary  paren- 
chyma, and  may  be  found  in  any  condition  causing  partial  collapse  of  the  lung. 

Perfect  tympanitic  resonance  may  be  obtained  in  that  very  rare  condition  in 
which  air  or  gas  collects  in  the  pericardium.  It  is  said  to  be  found  in  some  cases 
of  emphysema  and  of  acute  tuberculosis.  According  to  Da  Costa,  it  is  some- 
times found  in  pulmonary  oedema. 

Tympanitic  resonance  from  the  stomach  may  be  elicited  far  above  its 
normal  seat,  when  the  luug  is  retracted  and  the  stomach  and  intestines 
are  correspondingly  elevated. 

Vesiculo- tympanitic  resonance  is  a  quality  of  sound  midway  be- 
tween the  vesicular  and  the  tympanitic. 

This  sign  occurs  in  extreme  emphysema,  where  the  air  cells  and  the 
chest  walls  are  distended. 

Amphoric  resonance  is  a  modified  tympanitic  sound  which  may 
be  closely  imitated  by  tapping  the  cheek  gently  when  the  mouth  is  filled 
with  air.  but  not  much  distended.  The  sound  is  hollow  and  somewhat 
metallic.  It  is  obtained  in  very  much  the  same  conditions  as  cracked- 
pot  resonance — that  is,  over  an  empty  pulmonary  cavity  with  yielding 
walls;  but  to  produce  this  sign  the  cavity  must  communicate  freely  with 
a  large  bronchial  tube,  so  that  the  air  can  be  driven  quickly  from  it  by 
the  percussion  stroke.  It  is  found  also  over  collections  of  air  in  the 
pleural  sac,  when  this  cavity  opens  through  the  lung  into  a  large  bron- 
chus. 

Pulmonary  cavities  are  generally  caused  by  phthisis,  but  they  may 


THE  PLE8SIGRAPH.  31 

result  from  abscess.     Amphoric  resonance  is  therefore  a  sign  of  .pneumo- 
thorax, phthisis,  and  possibly  of  abscess  or  gangrene. 

Bell  Sound, — "While  listening  over  a  large  pulmonary  cavity,  if  percussion 
be  made  on  the  opposite  side  of  the  chest,  with  one  large  coin  striking  upon 
another  used  as  a  pleximeter,  a  ringing  bell  sound  will  be  heard,  which  is  some- 
times very  loud. 

Cracked-pot  resokajstce  {bruit  de  pot  fele)  may  be  imitated  by 
placing  the  hands  loosely  together,  palm  upon  palm,  and  striking  upon 
the  knee.  It  is  described  as  resembling  the  clinking  of  coin  or  the 
timbre  of  a  cracked  metallic  kettle.  Generally  the  sign  seems  to  be  the 
result  of  forcing  air  suddenly  from  a  pulmonary  cavity  through  a  small 
opening.  It  has  been  considered  by  some  as  diagnostic  of  a  pulmonary 
cavity,  but  this  sign  may  occasionally  be  obtained  when  no  cavity  exists, 
and  sometimes  even  in  healthy  individuals.  Something  closely  resem- 
bling this  resonance  is  apt  to  be  heard  during  percussion  if  the  plexim- 
eter is  placed  lightly  against  the  surface,  so  that  air  remains  beneath 
and  is  suddenly  forced  out  by  the  blow. 

It  is  said  that  occasionally  this  sound  may  be  elicited  in  the  bronchitis  of 
children,  or  just  above  the  level  of  the  fluid  in  pleurisy  with  effusion. 

As  a  rule,  cracked-pot  resonance  is  significant  of  a  cavity,  but  the  ma- 
jority of  cavities  do  not  produce  it.  When  found,  it  can  seldom  be 
heard  more  than  two  or  three  times  together,  and  it  requires  an  interval 
of  rest  before  it  can  be  reproduced.  This  is  probably  due  to  the  small 
opening  into  the  cavity — the  air,  having  been  driven  out,  returns  slowly. 

THE   PLESSIGRAPH. 

In  percussion  with  the  ordinary  pleximeter,  no  matter  what  its  material  or 
its  form  of  construction,  all  the  tissue  beneath  it  is  thrown  into  vibration.  This 
renders  it  next  to  impossible  to  define  sharply  the  outlines  of  dulness  when  solid 
tissue  is  overlapped  by  the  lung,  because  the  pleximeter  covers  too  much  space, 
and  the  sounds  from  the  tissues  containing  air  and  from  those  which  do  not  are 
blended.  For  instance,  in  attempting  to  determine  the  lower  border  of  the  lung, 
overlapping  the  liver,  we  commence  above  and  percuss  downward  to  the  point 
of  complete  flatness,  then  upward  ag-ain  to  a  point  where  the  vesicular  resonance 
is  clear,  and  thus  back  and  forth,  until  two  adjacent  points  are  reached  where 
we  obtain  on  the  one  hand  quite  perfect  pulmonary  resonance,  and  on  the  other 
flatness.  Then  we  judge  that  the  border  of  the  lung  lies  midway  between  the 
two. 

To  avoid  throwing  too  much  tissue  into  vibration,  the  size  of  the  pleximeter 
must  be  abridged  ;  but  as  the  size  is  diminished,  unless  compensated  for  in  some 
way,  the  intensity  of  the  sound  is  correspondingly  lessened.  These  difficulties 
seem  to  have  been  overcome  in  the  construction  of  a  little  instrument  known  as 
the  plessigraph  devised  by  M.  Peter,  of  Paris. 

It  consists  of  a  small  cylinder  of  wood  about  four  inches  in  length  and  five- 
eighths  of  an  inch  in  diameter,  with  a  disc  at  one  end  upon  which  percussion  is  to 
be  made.  The  other  end  consists  of  a  truncated  cone,  the  plane  surface  of  which 
measures  nearly  an  eighth  of  an  inch  in  diameter.     In  using  the  instrument,  the 


32  PHYSICAL  DIAGNOSIS. 

small  end  is  placed  on  the  surface  of  the  chest,  and  percussion  is  made  upon  the 
other  end  with  the  pulp  of  a  single  finger.  Care  must  be  taken  that  the  instru- 
ment is  held  perpendicular  to  the  surface.  On  account  of  the  smallness  of  the 
surface  which  rests  against  the  chest,  the  sound  obtained  would  be  very  feeble, 
were  it  not  in  a  measure  intensified  by  the  body  of  the  instrument  acting  as  a 
sounding-board.  Trousse;m  claimed  that  it  is  not  necessary  to  strike  upon  the 
disc,  but  that  we  may  simply  tap  upon  it  with  the  pulp  of  the  finger,  and  that 
by  means  of  this  instrument  even  students  may  rapidly  map  out  the  liver  or 
heart,  when  with  ordinary  percussion  this  might  be  impossible,  even  for  a  skilled 
diagnostician.  The  instrument  as  constructed  by  Peter  had  upon  the  side  an 
arrangement  holding  a  crayon  which  could  be  pressed  down  to  mark  the  skin 
when  the  border  of  the  organ  had  been  found,  so  that  a  dotted  line  would  be  left 
corresponding  to  the  outlines  of  the  solid  viscus  or  tumor.  I  have  found  this  in- 
strument very  satisfactory  in  determining  superficial  dulness,  so  long  as  it  is 
employed  only  in  the  intercostal  spaces,  but  not  when  applied  over  the  ribs. 

AUSCULTATORY   PERCUSSION. 

Auscultatory  percussion  was  instituted  by  Camman  and  Clark  in 
1840.  It  consists,  as  the  name  implies,  of  combined  auscultation  and 
percussion.  In  practising  it,  a  stethoscope  is  needed.  For  this  purpose 
the  originators  of  the  method  devised  a  peculiar  instrument,  which  con- 


Ftg.  11.— Camjian's  Stethoscope  for  Auscultatory  Percussion. 

sists  of  a  solid  cylinder  of  wood  formed  at  one  end  into  a  truncated 
wedge,  and  at  the  other  into  a  disc  (Fig.  11).  The  wedge-shaped  ex- 
tremity is  placed  in  an  intercostal  space,  over  the  most  superficial  por- 
tion of  the  organ  or  tumor  to  be  examined,  and  the  examiner's  ear  is 
placed  upon  the  disc.  An  assistant  then  percusses  from  the  healthy 
lung  tissue  toward  the  instrument.  The  moment  percussion  is  made 
over  solid  tissue,  the  changed  sound  reveals  the  fact  to  the  listener,  and 
thus  enables  him  to  determine  the  deep  outlines  of  the  solid  mass  much 
more  accurately  than  by  simple  percussion.  The  ordinary  binaural 
stethoscope  with  the  smaller  chest-piece  may  be  used  for  the  same  pur- 
pose. The  advantage  claimed  for  this  method  is  that  it  enables  one 
to  determine  the  outlines  of  intra-thoracic  tumors  or  organs  much  more 
accurately  and  rapidly  than  by  other  means.  Outlines  of  the  liver,  the 
spleen,  and  the  kidney  may  also  be  ascertained  with  considerable  accu- 
racy, even  when  ascites  is  present. 

In  the  practice  of  this  method,  a  second  person  has  been  necessary  to 
make  the  percussion,  and  it  is  often  impossible  to  get  a  skilled  assistant 
at  the  time  needed.  To  overcome  this  difficulty,  I  have  devised  an  in- 
strument known  as  the  emballometer  (Fig.  12).     It  consists  of  a  hoi- 


AUSCULTATORY  PERCUSSION.  33 

low  cylinder  about  three  inches  in  length  by  five-eighths  of  an  inch  in 
diameter,  within  which  plays  a  metallic  plunger.  Tc  the  objective  end 
of  the  instrument  is  fitted  a  soft-rubber  chest-piece,  against  which  the 
plunger  strikes.  To  the  other  end  is  attached  a  rubber  tube  about 
eighteen  inches  in  length,  connecting  it  with  a  rubber  bulb.  Compres- 
sion of  the  rubber  bulb  drives  the  plunger  against  the  chest-piece;  at 
the  instant  the  pressure  is  removed,  the  bulb  expands  and  the  plunger  is 
forced  upward  by  atmospheric  pressure.  In  practising  auscultatory 
percussion  by  the  aid  of  this  instrument,  the  stethoscope  is  held  with 


S-HARP    a     SMITH 


Fig.  12.— Ingals1  Emballometer. 


the  left  hand;  the  bulb  of  the  emballometer  is  held  in  the  palm  of  the 
right  hand  by  the  last  three  fingers,  and  the  cylinder  by  the  thumb  and 
forefinger.  This  enables  the  physician  to  move  the  instrument  without 
restraint,  to  strike  any  point  as  rapidly  or  as  slowly  as  he  chooses  and 
with  whatever  force  may  be  desirable.  By  means  of  this  little  instru- 
ment and  the  binaural  stethoscope,  auscultatory  percussion  can  be  satis- 
factorily practised  without  the  aid  of  an  assistant.  In  using  the  bin- 
aural stethoscope  for  this  purpose,  the  small  chest-piece  should  be 
employed.  Probably  one  still  smaller  or  flattened,  so  that  it  might  be 
applied  between  the  ribs,  would  give  even  better  results. 
3 


CHAPTEK    III. 

METHODS   OF  EXAMINATION. —Continued. 

AUSCULTATION. 

Auscultatiox,  the  art  of  listening  to  sounds  produced  within  the 
chest,  originated  early  in  the  present  century.  It  ranks  first  among  the 
methods  for  physical  exploration.  The  sounds  to  be  studied  by  this 
method  are  produced  during  either  insjfiration  or  expiration,  or  during 
both  portions  of  the  respiratory  act. 

Auscultation  may  be  mediate  or  immediate.  In  the  former,  the 
sounds  are  conducted  to  the  ear  through  an  instrument  known  as  the 
stethoscope;  in  the  latter,  the  ear  is  placed  directly  on  the  surface  of 
the  chest,  or  on  the  chest  but  slightly  covered. 

In  this  connection,  a  brief  notice  of  Laennec,  the  inventor  of  mediate  auscul- 
tation, is  of  peculiar  interest.  He  was  born  in  an  obscure  province  in  France, 
and  at  the  age  of  nineteen  went  to  Paris  to  obtain  his  medical  education,  where 
he  very  soon  attracted  the  attention  of  the  profession  by  his  diligence  and  atten- 
tiveness  at  the  hospitals. 

From  the  time  that  he  entered  Paris  until  his  final  departure,  about  five 
years  before  his  death,  his  whole  life  seems  to  have  been  given  to  careful  clinical 
study  and  verification  of  the  results  by  autopsy.  The  fruit  of  his  labor  we  find 
in  papers  written  on  inflammation,  melanosis,  encephaloid  cancer,  and  numerous 
other  topics,  but  especially  in  the  great  work  of  his  life,  his  treatise  on  ausculta- 
tion, published  in  1816,  when  the  author  was  about  thirty-five  years  of  age.  This 
was  the  introduction  of  auscultation  to  the  profession.  So  thorough  were  the 
author's  observations,  so  accurate  his  conclusions,  that  subsequent  writers  have 
been  able  to  add  but  little  to  the  information  upon  this  subject  gathered  by  him. 
Not  long  after  he  published  this  work,  close  application  began  to  undermine  his 
health,  and  in  a  few  years  the  very  method  which  he  had  introduced  disclosed 
the  signs  of  phthisis  in  his  own  chest.  Realizing  fully  their  significance,  he  re- 
signed his  work  in  Paris  and  retired  to  his  native  province,  where  he  died  at  the 
age  of  forty-five,  leaving  a  name  which  will  still  be  remembered  when  most  ot 
those  now  prominent  have  sunk  into  oblivion. 

Since  Laennec's  death,  the  method  known  as  immediate  auscultation, 
according  to  him  first  practised  by  Boyle,  has  received  great  favor  with 
the  profession.  Many  physicians  now  consider  this  the  only  proper 
method  of  auscultation,  while  a  few  others  rely  entirely  upon  the  medi- 
ate method.  "Whatever  the  advantages  of  either,  we  must  familiarize 
ourselves  with  both  to  become  accurate  diagnosticians. 

The  stethoscope  has  some  disadvantages.     The  first  and  main  objec- 


A  USCULTA  TION.  35 

tion  is  that  it  has  a  peculiar  ringing  sound  always  confusing  to  begin- 
ners. Until  we  become  sufficiently  familiar  with  the  instrument  to  ig- 
nore this,  we  shall  be  unable  to  appreciate  the  pulmonary  sounds.  Many 
of  these  instruments  are  poorly  constructed.  The  stethoscope  is  of  very 
little  value  in  examining  children,  because  it  is  likely  to  frighten  them; 
besides,  the  respiratory  murmur  in  them  is  so  loud  that  it  can  be  easily 
heard  with  the  unaided  ear. 

In  examining  the  lungs,  the  ear  alone  is  usually  sufficient;  but  to 
differentiate  between  the  sounds  produced  at  the  various  orifices  of  the 
heart,  we  must  employ  the  stethoscope,  the  small  chest-piece  of  which 
excludes  in  a  great  measure  all  sounds  excepting  those  produced  imme- 
diately beneath  it. 

Mediate  auscultation  has,  however,  the  advantage  of  greatly  intensify- 
ing the  intra-thoracic  sounds,  so  that  signs  which  could  not  be  heard  by 
the  unaided  ear  may  be  readily  recognized  through  the  instrument. 
Some  portions  of  the  chest  cannot  be  easily  examined  by  immediate 
auscultation — for  instance,  the  axillary  space  and  the  supra- clavicular 
region;  therefore  the  instrument  becomes  necessary;  sometimes  it  may 
be  unpleasant  to  apply  the  ear.  to  the  chest,  and  sometimes  for  the 
sake  of  delicacy  it  is  not  advisable. 

The  advantages  claimed  for  immediate  auscultation  are:  It  yields  no 
humming  sound;  it  obviates  the  necessity  of  carrying  an  instrument;  it 
does  not  frighten  little  children,  and  the  results  obtained  are  usually 
sufficiently  accurate. 

If  the  stethoscope  moves  slightly  upon  the  chest,  it  produces  a  grat- 
ing sound  much  more  intense  than  the  respiratory  murmur.  The  same 
thing  occurs  if  the  finger  moves  upon  the  instrument,  if  the  hand  is 
drawn  over  the  surface  of  the  chest,  or  if  the  patient's  clothes  move 
upon  the  chest  or  upon  the  instrument.  In  some  cases  neither  mediate 
nor  immediate  auscultation  alone  yields  accurate  results,  while  the  two 
combined  enable  us  to  make  a  proper  diagnosis. 

There  is  now  a  great  variety  of  stethoscopes.  They  may  be  classified, 
however,  as  solid  and  flexible,  some  of  which  are  binaural  and  others 
single.  The  binaural  instrument  is  provided  with  two  tubes  which  con- 
duct the  sound  simultaneously  to  both  ears.  The  single  stethoscope  is 
designed  only  for  one  ear.  The  solid  stethoscope  most  in  use  is  a  tubu- 
lar instrument  about  six  inches  in  length,  expanded  at  one  end  into  a 
bell-shaped  chest-piece  about  an  inch  and  a  fourth  in  diameter.  At  the 
other  extremity  is  a  disk  or  ear-piece  about  two  inches  in  diameter  (Fig. 
13).  Some  of  these  instruments  are  so  made  that  the  ear-piece  may  be 
removed  for  convenience  in  carrying,  and  a  soft-rubber  ring  encircles 
the  disk,  so  that  it  may  be  used  as  a  hammer  in  percussion.  I 
think  physicians  generally  find  more  difficulty  in  examining  the  chest 
with  this  instrument  than  with  the  binaural  stethoscope.  A  binaural 
stethoscope  devised  by  Leared,  of  London,  was  made  of  gutta-percha  and 


36 


PH  YSICA L  DIA  GNOSIS. 


consisted  of  two  tubes,  one  for  each  "ear.  The  auricular  extremities  of 
these  tubes  were  disk-shaped,  and  the  other  ends  were  fitted  into  a  hoi. 
low  cylindrical  or  cup-shaped  chest-piece.  The  elasticity  of  the  tubes 
kept  the  disks  in  firm  apposition  with  the  ears.  This  instrument  was 
exhibited  in  London  in  the  year  1851,  but  it  attracted  little  attention. 
About  the  same  time  Camman,  of  Xew  York,  introduced  the  binaural  in- 
strument that  bears  his  name.  This  consists  of  two  metal  tubes  so  curved 


Fig.  13.— Solid  Wooden  Stethoscope. 


as  to  fit  into  both  ears,  and  connected  with  each  other  by  a  hinge-joint. 
These,  when  placed  in  the  ears,  are  held  in  position  by  an  elastic  passing 
from  one  to  the  other  just  above  the  joint,  or  by  springs  of  various  con- 
trivance. The  auricular  ends  of  these  tubes  are  tipped  with  gutta-percha 
or  ivory  of  sufficient  size  to  close  the  external  meatus  and  prevent  the 
entrance  of  external  sounds.  To  the  other  ends  are  fitted  two  flexible 
tubes  which  connect  them  with  the  body  of  the  instrument  to  which 
the  chest-piece  is  attached  (Fig.  14).  Each  instrument  has  two  chest- 
pieces,  one  about  an  inch  and  a  quarter  in  diameter,  for  examination 


SHARP  — SMITH 


Fig.  14.— Knight's  Stethoscope,  with  Extension.  This  extension  tube  renders  it  easy  for  the 
student  to  examine  his  own  chest  and  is  a  great  convenience  in  examining  patients  in  bed. 

of  the  lungs;  the  other  five-eighths  of  an  inch  in  diameter,  for  the  ex- 
amination of  the  heart. 

Of  the  various  modifications  of  C'amman's  stethoscope,  Knight's  is 
the  best.  It  possesses  all  of  the  essential  points  of  a  good  instrument, 
viz. :    the  metallic  ear-tubes  are  curved  at  the  proper  angle  to  conduct 


A  USCULTA  TION.  37 

the  sound  directly  into  the  auditory  canal;  the  ear-tips  are  of  proper  size 
to  exclude  external  sounds,  and  are  not  so  small  as  to  pass  into  the  audi- 
tory canal  and  occasion  pain;  the  tubes  which  connect  the  ear-pieces 
with  the  chest-piece  are  very  pliable  and  have  a  calibre  equal  to  that  of 
other  portions  of  the  instrument;  the  chest-pieces  are  of  proper  size, 
and  the  whole  instrument  is  thoroughly  finished. 

With  many  instruments  a  soft-rubber  attachment  is  furnished  which 
may  be  fitted  over  the  end  of  the  smaller  chest-piece,  and  is  designed  for 
the  examination  of  emaciated  patients.  This  chest-piece,  however,  is 
practically  worthless,  on  account  of  the  creaking  which  is  produced,  dur- 
ing the  respiratory  movements,  by  friction  with  the  wooden  chest-piece 
on  which  it  is  adjusted. 

Charles  Dennison,  of  Denver,  has  an  excellent  modification  of  the 
binaural  instrument;  the  conducting  tubes  are  of  large  calibre,  com- 
posed of  gutta-percha  and  unite  in  a  common  tube  with  flaring  extremity 
about  an  inch  across;  into  this  three  other  chest-pieces  may  be  tightly 
fitted,  two  of  the  same  material,  one  of  medium  size  and  one  three  inches 
in  diameter.     The  latter  is  especially  valuable  when  it  is  desired  to  hold 


Fig.  15.— ALlison's  Differential  Stethoscope. 


the  chest-piece  of  the  stethoscope  before  the  patient's  open  mouth 
while  percussion  is  being  made  on  the  chest  as  recommended  when  the 
signs  of  consolidation  of  the  lung  are  indistinct.  The  third  chest-piece 
is  of  soft  rubber. 

The  differential  stethoscope  invented  by  Allison  is  essentially  the 
same  as  Camman's,  except  that  the  flexible  tubes  are  each  fitted  with  a 
distinct  chest-piece,  so  that  sound  can  be  conducted  to  the  two  ears 
simultaneously  from  different  portions  of  the  chest  (Fig.  15). 

A  stethoscope  which  will  fit  one  person  perfectly  and  allow  the 
sounds  to  be  conducted  without  obstruction  into  the  auditory  canal,  with 
another  may  rest  against  the  external  ear  in  such  a  position  as  nearly  to 
occlude  the  orifice  of  the  ear-piece;  therefore  in  purchasing,  one  should 
see  that  the  tubes  are  so  bent  that  the  instrument  fits  the  ears  accu- 
rately. The  larger  chest-piece  ought  never  to  exceed  one  and  one-fourth 
inches  in  diameter.  If  larger  than  this,  it  cannot  be  accurately  applied 
to  an  emaciated  patient;  consequently  air  passing  beneath  it  will  pro- 
duce a  humming  sound,  which  will  drown  the  pulmonary  signs. 


38  PHYSICAL  DIAGNOSIS. 

The  apparatus  on  Knight's  stethoscope  for  adjusting-  the  pressure  of  the  ear- 
pieces works  perfectly,  and  is  often  very  useful,  though  a  simple  rubber  hand  of 
proper  length  would  answer  the  purpose,  if  only  one  person  were  using  the  in- 
strument. A  rubber  band,  which  could  be  lengthened  or  shortened  by  a  buckle, 
would  allow  the  instrument  to  be  easily  adjusted  to  any  head,  and  would  be 
less  expensive  than  the  metal  attachment. 

Considerable  practice  is  required  to  perform  auscultation  properly. 
As  guides,  a  few  rules  may  be  laid  down : 

In  mediate  auscultation,  the  chest  must  be  bared;  in  immediate 
auscultation,  the  covering  must  be  as  soft,  thin,  and  smooth  as  possible. 

The  position  of  both  patient  and  examiner  should  be  easy  and  unre- 
strained. If  the  patient  is  in  bed,  it  is  preferable  to  have  him  sitting, 
if  health  will  permit.  If  the  examiner  is  in  an  uncomfortable  position, 
he  cannot  properly  concentrate  his  attention  upon  the  sounds. 

In  examining  a  child,  or  a  patient  in  bed,  it  is  a  good  plan  to  rest  on 
one  knee,  so  that  the  head  will  not  be  on  a  plane  lower  than  the  body, 
otherwise  gravitation  of  blood  to  the  brain  will  cause  fulness  of  the 
head,  dizziness,  and  impaired  sense  of  hearing. 

We  must  early  learn  to  concentrate  the  whole  attention  on  the 
sound  to  which  we  are  listening. 

It  is  desirable  to  have  the  room  quiet,  especially  in  practising  imme- 
diate auscultation,  for  the  ear  which  is  not  applied  to  the  chest  catches 
every  extraneous  sound,  unless  it  is  stopped  with  the  finger. 

The  ear  or  the  stethoscope  should  be  applied  firmly,  but  not  with 
great  force,  to  the  surface,  and  in  such  manner  that  no  air  can  pass 
beneath  it. 

Compare  corresponding  portions  of  the  two  sides  during  both  natural 
and  deep  respirations.  If  one  side  is  examined  during  ordinary  or  for- 
cible respiration,  the  other  must  be  examined  under  the  same  condi- 
tions. 

The  pulmonary  sounds  are  not  exactly  alike  in  any  two  individuals, 
nor  are  they  the  same  in  different  regions  of  the  chest  in  the  same  in- 
dividual; therefore  it  is  necessary  to  study  healthy  cases  carefully,  in 
order  to  become  familiar  with  all  varieties  of  healthy  sounds.  This 
familiarity  must  be  so  perfect  that  no  effort  of  the  mind  is  required  to 
remember  the  variations  in  different  localities.  This  cannot  be  urged 
too  forcibly,  because  until  we  can  easily  recognize  the  healthy  sounds 
it  is  absolutely  useless  for  us  to  attempt  to  detect  the  signs  of  disease. 

When  the  blood  leaves  the  right  side  of  the  heart,  surcharged  with 
carbonic  acid  and  other  debris  of  tissue  metamorphosis,  it  makes  a  pecul- 
iar impression  upon  the  respiratory  nerves,  which  is  transmitted  to  the 
brain  as  a  call  for  more  oxygen.  Instantly  a  message  is  flashed  back 
over  the  nerves,  to  the  inspiratory  muscles,  causing  them  to  contract. 
By  this  action  the  diaphragm  is  shortened  and  its  convexity  lessened; 
the  ribs  are  lifted,  and  by  rotation  on  their  articulations  with  the  spinal 
column,  they  are  at  the  same  time  carried  forward  and  outward.     Thus 


AUSCULTATION  IN  HEALTH.  39 

the  diameters  of  the  chest  are  increased  in  every  direction,  and  air  rush- 
ing in  through  the  open  glottis  distends  the  elastic  lungs  as  the  chest 
expands.  Immediately  the  respiratory  act  ceases,  the  muscles  relax,  the 
elastic  tissue  of  the  lung  asserts  itself,  and  the  air  is  expelled  from  the 
pulmonary  vesicles.  This  latter  is  a  passive  movement,  in  which  the 
expiratory  muscles  take  little  part,  excepting  in  forcihle  expiration. 

While  inspiration  is  taking  place,  we  hear  a  soft,  breezy,  or  rustling 
sound,  known  as  the  inspiratory  murmur.  As  soon  as  it  ceases,  a  sound 
soft  and  breezy,  but  less  intense  and  much  shorter,  occurs,  which  is  the 
expiratory  murmur.  This  is  followed  by  a  period  of  rest,  which  com- 
pletes the  cycle  of  respiration. 

AUSCULTATION   IX   HEALTH. 

A  variety  of  signs  may  be  obtained  in  the  normal  chest  owing  to  the 
position  of  surrounding  organs,  and  the  difference  in  the  force  and  vol- 
ume of  the  air  current  producing  the  sounds. 

Auscultatory  sounds  are  possessed  of  elements  similar  to  those  of  the 
percussion  sounds,  viz.,  intensity,  pitch,  quality,  duration,  and  in  addi- 
tion, rhythm.  The  latter  refers  to  the  relation  between  the  different 
portions  of  the  respiratory  act.  The  intensity  of  the  sound  varies  in 
different  people.  The  pitch  and  the  quality  are  practically  the  same  in 
all  healthy  cases. 

The  duration  of  the  sound  also  varies  in  different  cases,  but  is  about 
equal  to  the  duration  of  the  respiratory  act  which  produces  it.  All 
modifications  of  the  respiratory  murmur  which  may  be  obtained  in  (lif- 
erent regions  of  the  chest  are  simply  alterations  in  one  or  more  of  these 
elements.  Thus  in  the  different  parts  of  the  respiratory  tract  we  ob- 
tain the  normal  vesicular  murmur,  bronchial  respiration,  and  tracheal 
and  laryngeal  respiration,  each  of  which  differs  from  the  others  more  or 
less  in  intensity,  pitch,  quality,  duration,  and  rhythm.  The  clearest 
vesicular  murmur  is  obtained  in  the  infra-clavicular  and  infra-scapular 
'regions.  Laryngeal  respiration  and  tracheal  respiration  are  obtained 
over  the  larynx  and  the  trachea,  and  are  essentially  the  same.  Bronchial 
respiration,  or  more  properly  broncho-vesicular  respiration,  may  be  heard 
over  the  bronchial  tubes,  and  for  an  inch  or  more  about  them  in  every 
direction  upon  either  the  anterior  or  the  posterior  surface  of  the  chest. 

The  vesiculae  mtjemue,  which  is  the  sound  obtained  over  the 
pulmonary  parenchyma,  is  taken  as  the  standard  of  comparison  for  all 
others.  This  sound  may  be  best  studied  in  the  infra-scapular  region, 
though  it  is  more  intense  in  front,  below  the  clavicle:  but  in  the  latter 
position  the  heart  sounds  interfere  with  its  easy  recognition.  The  vesic- 
ular murmur,  like  all  other  respiratory  sounds,  is  possessed  of  two  parts. 
The  first  of  these,  the  inspiratory,  begins  as  a  soft  and  distant  blowing 
sound,  and  gradually  increases  in  intensity  and  approaches  more  nearly 
to  the  ear  toward  the  end  of  the  act,  when  it  is  breezy  or  rustling  in 


40  PHYSICAL  DIAGNOSIS. 

character.  It  varies  in  intensity  in  different  individuals,  but  is  gener- 
ally easily  heard.  Its  pitch  is  low;  in  duration  it  corresponds  with  the 
inspiratory  act.  Its  quality,  called  vesicular,  cannot  be  accurately  de- 
scribed, though  it  may  be  easily  learned  by  practice  upon  a  healthy  chest. 
This  sound  is  followed  immediately  by  a  gentle  rustling  sound,  the  ex- 
piratory murmur,  which  passes  off  gradually  into  a  low  breath  or  puff. 
It  is  less  intense  than  tbe  preceding,  being  usually  so  feeble  that  one 
must  listen  for  it  very  attentively ;  it  is  of  the  same  low  pitch,  and  about 
one-fourth  the  duration  of  the  inspiratory  sound.  Though  termed  vesic- 
ular, its  quality  is  neither  strictly  vesicular  nor  bronchial,  but  slightly 
blowing. 

The  normal  vesicular  murmur  is  modified  in  different  regions  of  the 
chest,  by  the  size  of  the  bronchial  tubes,  and  more  or  less  by  the  thick- 
ness of  the  chest  walls  and  by  the  position  of  other  organs.  It  is  heard 
in  perfection  in  the  left  infra- clavicular  region.  On  the  right  side  the 
sound  is  more  intense,  and  the  expiratory  sound  generally  slightly  pro- 
longed ;  this  disparity  being  due  evidently  to  the  direction  and  size  of 
the  right  bronchus  as  compared  with  the  left.  There  may  be  a  very  slight 
interval  between  the  inspiratory  and  expiratory  murmurs,  and  the  qual- 
ity of  both  is  usually  slightly  tubular. 

Over  the  upper  portion  of  the  sternum  and  the  inner  third  of  the 
infra-clavicular  regions,  the  proximity  of  the  trachea  and  of  the  large 
bronchial  tubes  renders  the  normal  murmur  somewhat  tubular  or  bron- 
cho-vesicular in  quality. 

In  the  inter-scapular  space,  owing  to  the  thickness  of  the  chest  walls, 
the  vesicular  sounds  are  less  distinct;  owing  to  the  presence  of  the  main 
bronchi,  they  are  more  tubular  in  character,  so  that  in  this  position  also 
we  find  a  sound  which  might  properly  be  termed  the  broncho-vesicular 
murmur,  but  which  is  usually  called  normal  bronchial  breathing. 

In  the  scapular  regions,  the  thickness  of  the  chest  wall  renders  the 
vesicular  sound  indistinct. 

In  children,  the  vesicular  murmur  is  much  more  intense  than  in 
adults.  Over  the  upper  portion  of  the  chest  it  is  usually  much  more 
intense  in  women  than  in  men.  In  the  aged,  it  frequently  loses  some- 
thing of  its  soft  quality,  and  becomes  slightly  more  tubular,  and  is 
altered  in  its  rhythm,  the  expiratory  sound  being  occasionally  preceded 
by  a  short  period  of  silence,  and  having  a  duration  nearly  or  quite  equal 
to  the  inspiratory  murmur.  This  change  seems  due  to  partial  atrophy 
of  lung  tissue  and  to  changes  in  the  elasticity  of  the  chest  walls. 

In  extreme  anaemia,  the  vesicular  murmur  is  intensified  over  the  en- 
tire chest. 

In  listening  to  the  respiration  of  muscular  subjects,  a  continuous,  low- 
pitched,  superficial,  rumbling  murmur  is  heard  where  the  muscles  are 
thickest,  which  is  due  to  the  contraction  of  muscular  fibres.  In  rare 
cases  this  is  so  marked  as  closely  to  resemble  the  vesicular  murmur. 


AUSCULTATION  IN  DISEASE.  41 

Laryngeal  asd  Tracheal  Kespiration. — The  respiratory  murmur 
over  the  larynx  and  the  trachea  differs  from  vesicular  respiration  in  its 
intensity,  pitch,  quality,  duration,  and  rhythm.  The  inspiratory  sound 
is  much  more  intense  than  in  the  vesicular  murmur,  its  pitch  is  higher, 
its  quality  tubular,  and  there  is  a  marked  interval  between  it  and  the 
expiratory  sound. 

The  expiratory  sound  is  generally  more  intense  than  the  inspiratory, 
and  even  higher  in  pitch.  It  has  the  same  tubular  quality  and  about 
the  same  duration.  To  sum  up  these  points  of  distinction,  laryngeal  and 
tracheal  respiration  differs  from  the  vesicular  in  being  more  intense, 
higher  pitched,  and  tubular  in  quality-  in  having  an  interval  between 
the  two  portions  of  the  act,  and  the  expiratory  sound  is  as  long  as  the 
inspiratory,  or  even  of  greater  duration. 

Bronchial  respiration,  or,  perhaps  more  properly,  broncho- 
vesicular  respiration,  is  next  in  importance  to  the  vesicular.  It 
may  always  be  found  in  the  healthy  chest,  but  is  only  heard  in  a  limited 
area,  immediately  over  and  surrounding  the  large  bronchial  tubes.  The 
latter  term  seems  more  appropriate,  as  this  combines  both  the  bronchial 
and  the  vesicular  varieties.  True  bronchial  breathing  is  the  same  as 
tracheal,  excepting  that  it  is  usually  less  intense*  It  is  the  sound  ob- 
tained in  pulmonary  diseases  where  the  air  vesicles  are  completely  filled 
by  inflammatory  lymph  or  other  products.  Broncho-vesicular  respira- 
tion holds  a  place  midway  between  bronchial  and  vesicular,  and  is  the 
sound  obtained  when  only  a  portion  of  the  air  vesicles  are  occluded. 

The  sound  heard  over  the  main  bronchial  tubes  in  the  healthy  chest 
is  more  intense  than  the  vesicular  murmur,  and  its  pitch  is  higher;  its 
quality  is  a  combination  of  the  vesicular  and  tubular,  and  a  slight  inter- 
val may  be  noticed  between  inspiration  and  expiration.  The  expiratory 
sound  is  of  nearly  equal  duration  with  the  inspiratory. 

"We  shall  at  once  perceive  the  necessity  of  being  able  to  recognize 
these  normal  sounds  and  of  knowing  the  localities  in  which  they  occur; 
for  some  of  these,  when  heard  in  abnormal  positions,  are  the  signs  of 
grave  diseases. 

auscultation  in  disease. 

The  auscultatory  sounds  are  altered  by  disease,  principally  iu  their 
intensity,  rhythm,  and  quality. 

The  intensity  may  be  increased,  giving  rise  to  exaggerated,  compen- 
satory, or  supplementary  respiration.  It  may  be  diminished,  and  is  then 
called  feeble  respiration;  or  the  sounds  may  be  entirely  suppressed.  The 
rhythm  of  the  murmur  may  be  interrupted.  It  is  then  termed  jerking, 
wavy,  or  cog-wheel  respiration ;  and  the  interval  between  the  two  portions 
of  the  act  may  be  lengthened,  or  the  expiratory  sound  may  be  prolonged. 

The  quality  of  the  sound  may  be  rude,  termed  broncho-vesicular, 
or  bronchial,  cavernous,  or  amphoric. 


42  PHYSICAL  DIAGNOSIS. 

Exaggerated  respiration  differs  from  the  normal  murmur  in  in- 
tensity and  duration,  both  the  inspiratory  and  the  expiratory  sounds 
being  intensified  and  somewhat  prolonged.  It  is  produced  in  lung  tissue 
which  is  performing  more  than  its  ordinary  function.  When  obtained 
over  the  chest  of  an  adult  it  closely  resembles  the  natural  sound  in  a 
child,  and  hence  has  been  termed  puerile  respiration.  It  is  also  termed 
supplementary  or  compensatory  respiration.  Like  exaggerated  percus- 
sion resonance,  it  may  be  said  to  indicate  the  highest  degree  of  health  in 
the  organs  where  it  is  produced;  but  it  also  points  to  disease  of  some 
other  portion  of  the  respiratory  tract,  and  is  therefore  a  valuable  nega- 
tive sign.  It  results  from  any  condition  which,  by  interfering  with  the 
entrance  of  air  into  one  portion  of  the  respiratory  organs,  may  cause 
more  activity  in  the  remainder.  Thus, partial  consolidation,  collapse,  or 
compression  of  the  lung  gives  exaggerated  respiration  well  marked  in  the 
sound  portion  of  the  affected  organ,  and  more  or  less  also  on  the  sound 
side.  So  also  obstruction  of  a  bronchial  tube  by  secretion  or  diminution 
in  its  calibre,  by  compression  from  tumors  or  thickening  or  contraction  of 
its  wall,  may  give  rise  to  this  sign  in  the  portions  of  the  lung  not  thus 
obstructed. 

(Edema  of  the  lungs  may  also  cause  exaggerated  respiration  over  their 
apices  ;  and  in  hemiplegia,  more  or  less  paralysis  of  the  respiratory  mus- 
cles on  one  side  causes  exaggerated  respiration  on  the  other. 

Feeble  respiration  differs  from  the  normal  vesicular  murmur  in 
being  less  intense  and  shorter  in  duration.  The  inspiratory  part  of 
the  sound  is  most  affected.  The  sign  may  be  occasioned  by  anything 
which  interferes  with  the  perfect  transmission  of  sounds  to  the  surface, 
as  thick  chest  walls  whether  due  to  muscular  or  to  adipose  tissue;  it  is 
also  caused  by  small  quantities  of  air,  fluid,  or  inflammatory  lymph  in 
the  pleural  sac. 

It  may  result  from  loss  of  elasticity  of  the  lung  tissue  in  consequence 
of  dilatation  of  the  air  vesicles,  as  in  pulmonary  emphysema,  or  from 
tubercular  or  inflammatory  consolidation  of  the  lung;  also  from  defi- 
cient action  of  the  respiratory  muscles,  occurring  in  paralysis;  or  it  may 
exist  in  diseases  of  the  abdominal  or  thoracic  organs  which  give  rise  to 
pain  and  cause  the  patient  to  restrain  muscular  movement. 

Collections  of  fluid  or  gas  in  the  pleural  cavit}',  tumors  in  the  chest 
or  abdomen  or  a  pregnant  uterus  may  interfere  with  the  function  of 
the  lung,  and  prevent  the  descent  of  the  diaphragm  by  mechanical  pres- 
sure, thus  causing  feeble  respiration. 

Obstructions  of  the  larynx,  trachea,  or  bronchi  also  cause  feeble  respi- 
ration resulting  from  collection  of  fluids,  the  presence  of  foreign  bodies, 
thickening  of  the  walls  by  inflammation,  diphtheritic  or  croupous  de- 
posits, oedema,  and  neoplasms;  from  contraction  of  the  walls,  as  in 
asthma,  spasm  of  the  glottis,  or  paralysis  of  its  dilators;  or  through  com- 
pression from  without  by  inflammatory  growths,  tumors,  and  the  like. 


AUSCULTATION  IN  DISEASE.  43 

When  this  diminished  murmur  is  found  in  the  upper  part  of  one 
lung,  it  often  indicates  phthisis;  if  found  in  the  lower  part  of  the  lung, 
it  is  very  often  an  indication  of  pneumonia;  found  over  the  lower  por- 
tion of  both  lungs,  it  is  suggestive  of  oedema. 

Suppressed  respiration  is  due  to  the  same  causes  which,  occurring 
in  a  less  degree,  give  rise  to  feeble  respiration.  It  is  often  observed 
over  the  diseased  portion  of  a  lung,  the  remainder  of  which  yields  the 
exaggerated  respiratory  murmur. 

IN  INTERRUPTED  RESPIRATION,  also  known  as  COG-WHEEL  RESPIRA- 
TION, either  inspiration,  expiration,  or  both  may  be  broken  into  two  or 
more  parts,  the  sound  being  suddenly  interrupted,  to  return  again,  and 
perhaps  again  and  again,  before  a  single  respiration  is  complete.  The 
interruption  takes  place  most  frequently  with  inspiration.  The  sign  is 
found  under  a  variety  of  circumstances,  not  only  in  disease,  but  also  in 
health,  so  that  it  is  not  of  much  importance,  though  sometimes  helpful 
in  confirming  a  diagnosis  based  on  other  evidence.  It  is  sometimes 
present  over  the  whole  chest,  at  other  times  confined  to  a  limited 
space. 

When  occurring  in  health,  it  is  often  heard  over  the  whole  chest;  but 
when  resulting  from  pulmonary  disease,  it  is  more  apt  to  be  localized. 
In  the  incipiency  of  phthisis  this  sign  is  frequently  obtained  directly 
over  the  diseased  lung,  especially  when  the  lesions  are  in  the  left 
apex. 

It  may  be  produced  by  any  disease  which  renders  respiration  painful, 
as  intercostal  neuralgia,  pleurisy,  and  pleurodynia.  It  also  occurs  in 
nervous  persons  when  agitated  by  the  examination,  and  is  very  apt  to 
be  found  in  hysterical  patients.  When  due  to  nervousness  or  pain,  the 
sign  will  be  found  over  the  whole  of  one  or  both  lungs. 

As  an  indication  of  disease,  interrupted  respiration  is  a  sign  of  very 
little  value,  excepting  in  the  early  stage  of  phthisis. 

In  incipient  phthisis  the  immediate  cause  of  this  sign  seems  to  be  forcible 
contraction  of  the  heart,  whereby  an  abnormal  amount  of  blood  is  forced  into 
the  pulmonary  circuit,  thereby  causing  some  narrowing  of  the  calibre  of  the 
bronchial  tubes. 

A  prolonged  interval  between  inspiration  and  expiration  may  be 
caused  by  shortening  of  the  inspiratory  murmur,  or  by  a  delay  in  the  com- 
mencement of  the  expiratory  murmur. 

Shortened  Inspiration. — The  inspiratory  sound  in  this  condition 
ceases  before  the  act  is  complete  and  is  consequently  shortened,  in  partial 
consolidation  of  the  lung  due  to  inflammatory  or  tubercular  deposits. 
It  is  deferred  in  its  commencement  after  the  inspiratory  act  begins,  and 
thus  is  shortened  where  the  air  vesicles  are  dilated. 

Deferred  Expiration. — The  expiratory  sound  is  delayed  when  the  air 
vesicles  are  distended,  as  in  pulmonary  emphysema. 


44  PHYSICAL  DIAGNOSIS. 

Prolonged  expiration  results  from  a  loss  of  elasticity  of  the  lungs, 
either  by  consolidation  or  by  distention. 

When  due  to  consolidation,  a  prolonged  expiratory  murmur  is  usually 
more  intense  than  normal.  It  is  high  pitched  and  more  or  less  tubular 
in  quality,  and  usually  possesses  so  much  of  the  bronchial  element  as  to 
be  termed  broncho-vesicular. 

The  prolonged  expiratory  murmur  which  is  sometimes  found  in  healthy 
chests  possesses  the  same  pitch  and  quality  as  the  normal  vesicular  sound,  which 
enables  us  to  distinguish  it  from  the  prolonged  expiration  of  consolidation,  in 
which  the  pitch  is  always  high  and  the  quality  somewhat  tubular.  We  must 
not  forget  that  in  health  the  vesicular  murmur  over  the  right  apex  is  sometimes 
more  or  less  tubular  and  high  in  pitch,  and  that  the  expiratory  sound  is  pro- 
longed, as  compared  with  the  left  side.  Therefore,  in  this  position  the  sign  can- 
not always  be  considered  as  indicative  of  disease,  unless  it  be  taken  in  connection 
with  other  signs. 

When  obtained  on  the  left  side,  prolonged  expiration  is  nearly  always 
due  to  phthisis  or  to  emphysema.  The  difference  in  the  two  is  that  in 
consumption  the  expiratory  sound  is  high  pitched  and  more  or  less 
tubular  in  quality;  while  in  emphysema  it  is  usually  even  more  pro- 
longed— it  may  be  two  or  three  times  as  long  as  the  inspiratory  murmur 
— and  it  has  a  low  pitch,  it  is  not  tubular  but  rather  vesicular  in  quality, 
and  is  apt  to  be  considerably  less  intense  than  the  inspiratory  sound. 

Occasionally  prolonged  expiration  may  be  caused  by  interference  with  the 
free  exit  of  air  from  the  lungs,  as  by  obstruction  in  the  larynx  or  bronchial  tubes. 
In  these  cases  it  is  usually  associated  with  a  deferred  inspiratory  murmur,  in 
which  the  sound  does  not  begin  with  the  inspiratory  act. 

Exceptional. — Prolonged  expiration  having  the  pitch  and  quality  of  the 
healthy  murmur  is  obtained  with  cavernous  respiration  in  rare  cases.  In  such 
instances  its  significance  is  ascertained  by  the  character  of  the  inspiratory  sound 
and  by  other  signs. 

Rude  respiration  (broncho-vesicular  or  harsh  respiration) 
closely  resembles  the  sound  which  can  be  obtained  directly  over  the 
bronchial  tubes  in  a  healthy  chest. 

The  respiratory  sound  is  raised  in  pitch  in  proportion  as  the  tubular 
supplants  its  vesicular  quality.  The  expiratory  sound  is  always  higher 
in  pitch  than  the  inspiratory,  its  quality  is  more  or  less  tubular,  and  it 
is  prolonged.  The  alteration  in  pitch  and  duration  is  in  proportion  to 
the  preponderance  of  the  tubular  over  the  vesicular  quality. 

Disease  may  furnish  all  degrees  of  broncho-vesicular  respiration  from 
the  normal  vesicular  murmur  to  perfect  bronchial  breathing,  according 
to  the  amount  of  consolidation. 

This  sign  is  due  to  the  better  transmission  of  the  vibrations  from  the 
larynx,  trachea,  and  bronchial  tubes  to  the  surface  of  the  chest,  in  con- 
sequence of  the  consolidation  of  the  air  vesicles,  making  the  parenchyma 
a  better  conductor  of  sound-waves  and  rendering  the  bronchial  tubes 


AUSCULTATION  IN  DISEASE.  45 

more  rigid,  so  that  they  transmit  these  waves  from  the  upper  air  passages 
with  less  resistance. 

The  sign  is  obtained  in  incipient  phthisis  over  the  upper  part  of  the 
lung,  and  in  pneumonia,  usually  over  the  lower  lobe.  It  is  also  heard 
in  some  cases  of  pulmonary  apoplexy,  and  over  a  lung  partially  collapsed 
from  any  cause  or  which  has  been  compressed  for  a  considerable  time 
by  fluid  or  air  in  the  pleural  sac.  It  is  most  valuable  as  a  sign  of  incip- 
ient phthisis. 

Exceptional. — Occasionally  in  cases  where  broncho-vesicular  respiration  oc- 
curs, either  the  inspiratory  or  expiratory  murmur  may  be  absent ;  then,  as  in 
similar  instances  of  bronchial  respiration,  its  detection  will  depend  on  the  pitch 
and  quality  of  the  sounds  which  are  present,  and  upon  concomitant  signs. 

Beoxchial  eespieatiox  is  one  of  the  most  important  varieties  of 
the  healthy  sounds,  which  may  sometimes  be  indicative  of  disease.  Its 
quality  and  its  other  elements  excepting  its  intensity  are  much  the  same 
as  those  of  normal  tracheal  respiration.  The  intensity  of  this  sound  is 
usually  greater  by  far  than  that  of  the  vesicular  murmur,  but  sometimes 
very  feeble;  the  pitch  is  high,  the  quality  tubular,  and  the  duration  of 
both  inspiration  and  expiration  is  prolonged,  the  two  being  of  about 
equal  length.  There  is  an  appreciable  interval  between  the  inspiratory 
and  expiratory  sounds. 

Exceptional. — In  bronchial  respiration,  either  portion  of  the  respiratory 
murmur  may  sometimes  be  absent. 

Laennec  taught  that  the  bronchial  sound  was  always  produced  in  a 
healthy  chest,  but  that  it  was  not  usually  heard  because  of  the  interven- 
tion of  air  vesicles  between  the  tubes  and  the  chest  walls.  When  ob- 
tained in  disease,  he  considered  the  sign  due  simjjly  to  the  better  trans- 
mission of  the  sounds  to  the  surface.  Skoda  believed  that  consolidation 
of  the  air  vesicles  surrounding  the  bronchus  was  necessary  for  the  pro- 
duction of  the  perfect  sign.  Whichever  of  these  views  is  correct,  or 
whether  both  are  in  part  true,  matters  little  to  us,  so  long  as  we  know 
that  the  sign  always  indicates  consolidation  of  lung  tissue  (Fig.  27). 
The  tubular  sounds  in  this  variety  of  the  respiratory  murmur  'are 
transmitted  for  a  considerable  distance  beyond  the  consolidated  lung, 
which  accounts  for  the  fact  that  the  bronchial  and  the  vesicular  elements 
are  frequently  combined  in  the  regions  immediately  surrounding  that 
which  yields  simply  bronchial  respiration. 

The  greater  intensity  of  the  expiratory  sound  in  bronchial  respiration  ac- 
counts for  the  fact  that  occasionally  we  obtain  a  vesicular  inspiratory  and  a 
bronchial  expiratory  sound,  as  the  intensity  of  the  bronchial  sound  drowns  the 
vesicular  in  expiration. 

Bronchial  respiration  is  found  in  greatest  perfection,  in  pneumonia, 
over  the  consolidated  lung.  It  is  obtained  also  in  some  cases  of  phthisis, 
but  in  this  affection  we  are  more  apt  to  hear  broncho-vesicular  respiration. 


46  PHYSICAL  DIAGNOSIS. 

Exceptional. — In  rare  cases  cancer  of  the  lung  yields  bronchial  breathing. 
Pulmonary  apoplexj'  sometimes  causes  the  sign  ;  it  is  heard  over  the  entire 
chest,  though  more  distant  than  in  consolidation,  in  a  few  cases  of  pleurisy  with 
extensive  effusion. 

Cavernous  respiration  has  been  likened  to  both  bronchial  and 
vesicular.  We  are  told  by  one  author  that  it  closely  resembles  the  former, 
and  by  another  that  great  care  is  necessary  to  distinguish  it  from  the 
latter.  This  discrepancy  is  probably  due  to  confusion  in  the  application 
of  the  term  to  different  signs.  Flint  made  the  distinction  clear  by  in- 
troducing the  term  broncho-cavernous  to  designate  those  hollow,  high- 
pitched  sounds  which,  although  conveying  the  idea  of  a  cavity,  do  not 
correspond  with  true  cavernous  respiration.  The  intensity  of  cavernous 
respiration  is  usually  feeble,  so  that,  unless  searched  for  carefully,  it  will 
be  overlooked.  The  pitch  is  low,  and  the  quality,  instead  of  being  vesic- 
ular or  tubular,  is  soft  and  blowing  or  puffing.  The  expiratory  portion 
of  the  sound  is  prolonged  to  about  the  same  length  as  the  inspiratory, 
and  is  even  lower  in  pitch  than  the  latter.  The  failure  of  some  diagnos- 
ticians to  appreciate  the  quality  of  this  sound  has  caused  them  to  deny 
its  existence.  I  have  occasionally  heard  the  true  cavernous  murmur  as 
just  described,  but  I  think  it  a  very  rare  sign.  It  is  produced  in  empty 
pulmonary  cavities,  the  walls  of  which  are  so  flaccid  that  they  expand 
readily  in  inspiration  and  collapse  in  expiration  (Fig.  16).  It  is  a  sign, 
therefore,  of  any  of  those  diseases  which  might  cause  such  a  cavity,  viz.y 
consumption,  pulmonary  abscess,  or  gangrene  of  the  lung. 

Broncho-cavernous  respiration  is  made  up  of  both  the  bronchial  and 
the  cavernous  sounds.  It  is  usually  described  as  cavernous,  but  it  is 
higher  in  pitch  and  more  tubular  in  quality  than  the  latter.  Its  quality 
is  not  sufficiently  tubular  to  be  called  bronchial,  nor  yet  sufficiently  soft 
and  puffing  to  be  termed  cavernous.  It  is  produced  in  pulmonary  cav- 
ities, surrounded  by  lung  tissue  more  or  less  consolidated;  the  tubular 
element  being  dependent  upon  the  amount  of  consolidation.  Sometimes 
the  first  part  of  the  inspiratory  murmur  may  be  tubular  in  quality  and 
the  last  part  cavernous;  again,  we  may  obtain  cavernous  inspiration  with 
bronchial  expiration,  due  to  the  presence  of  consolidated  lung  tissue 
near  the  cavity.  In  the  latter  case  the  intense  expiratory  bronchial 
murmur  probably  drowns  the  cavernous  sound  which  was  heard  with 
the  feebler  inspiratory  murmur. 

Broncho-cavernous  respiration  is  the  characteristic  sign  of  the  later 
stages  of  consumption,  but  it  may  also  be  produced  in  the  cavities  due 
to  abscess  or  to  gangrene. 

Amphoric  respiration  resembles  the  sound  produced  by  blowing 
into  the  mouth  of  an  empty  bottle,  hence  the  name.  It  is  of  a  metallic 
musical  quality,  and  may  be  heard  during  either  inspiration  or  expira- 
tion, or  during  both  portions  of  the  respiratory  act,  but  is  generally  most 
marked  in  expiration.     The  expiratory  sound  is  lower  in  pitch  than  that 


AUSCULTATION  IN  DISEASE. 


47 


in  bronchial  respiration.  In  this  connection  it  is  well  to  emphasize  the 
necessity  of  studying  the  pitch  of  the  respiratory  sounds,  for  in  some 
instances  there  is  absolutely  no  other  means  of  distinguishing  between 
the  sounds  transmitted  from  the  bronchial  tubes  in  consolidated  lungs 
and  those  heard  over  pulmonary  cavities.  The  distinction  in  these  cases 
is  clear  if  we  remember  that  the  expiratory  sound  in  the  former  instance 
is  always  high  in  pitch,  in  the  latter  always  low. 

Amphoric  respiration  occurs  under  the  same  conditions  as  amphoric 
resonance,  and  is  frequently  found  in  connection  with  cracked-pot  reso- 
nance.    It  is  due  to  the  passage  of  air  in  and  out  through  an  opening 


Gurgles 


Gvmi WITHOUT So 


Fig.  16.— Phthisis. 


from  a  bronchus  into  a  large  pulmonary  cavity  or  into  the  pleural  sac 
(Fig.  26).  Tbe  sign  is  obtained  most  perfectly  in  pneumothorax  or  in 
pneumo-hydrothorax.  In  the  latter  it  disappears  and  returns  again,  as 
the  quantity  of  fluid  rises  so  as  to  cover  the  oj)ening  or  falls  below  it. 
This  sign  is  also  heard  in  phthisis  when  the  pulmonary  cavity  is  large- 
and  its  walls  are  firm,  so  that  they  will  not  collapse  in  expiration. 

Cavities  may  exist  within  the  lungs  without  yielding  either  of  the 
varieties  of  respiration  which  may  be  caused  by  a  vomica;  for  example, 
if  a  cavity  be  filled  with  fluid,  or  if  the  fluid  in  the  cavity  rise  above  the 
orifice  of  the  bronchial  tube,  none  of  these  sounds  will  be  heard  (Fig. 
16);  but  if  the  patient's  position  be  chauged  or  the  amount  of  fluid  de- 
creased by  coughing,  the  signs  return. 


CHAPTEE  IV. 


METHODS   OF   EXAMINATION— Continued. 


ADVENTITIOUS  SOUNDS. 

The  auscultatory  sounds  -which  we  have  thus  far  been  studying  are 
6uch  as  may  be  obtained,  in  more  or  less  perfection,  over  the  healthy 
chest.  Certain  accidental  or  adventitious  sounds  occur  only  in  disease. 
These  may  accompany  normal  sounds  or  take  their  place,  and  will  vary 
according  to  their  origin.  Those  produced  -within  the  lungs  are  called 
rales  or  ronchi;  those  upon  the  pleural  surfaces  are  termed  friction 
sounds. 

Eale>. — Bales  are  as  numerous  and  as  different  in  variety  as  the 
shades  of  color,  but  they  may  be  grouped  into  a  few  distinct  classes, 
•which  are  generally  capable  of  some  peculiar  interpretation.  All  of  them 
are  either  dry  or  moist;  hence  we  may  group  the  different  sounds  under 
one  of  these  heads,  according  to  peculiarities  in  their  pitch  and  quality, 
as  shown  below: 


Rales, 
or  rhonchi, 


Dry. 


Moist. 


j    Sonorous  rales. 
(    Sibilant  rales. 


Mucous  rales  (large  and  small). 
Subcrepitant  rales. 
Crepitant  rales. 


Gurgles  (large  and  small). 
Mucous  click. 

Rales  may  originate  in  the  larynx,  trachea,  bronchial  tubes,  air  vesi- 
cles, or  in  any  cavity  connected  with  the  bronchial  tubes.  They  are  pro- 
duced by  various  conditions  which  interfere  with  the  passage  of  air 
through  the  tubes  and  into  the  air  vesicles,  and  may  be  heard  in  inspi- 
ration or  expiration,  or  during  both  portions  of  the  respiratory  act. 

Dry  rales  are  distinguished  as  sonorous  or  sibilant  according  to 
their  pitch,  which  depends  on  the  size  of  the  bronchial  tube  in  which 
they  are  produced. 

Sonorous  rales  are  usually  musical,  or  snoring  in  quality,  resembling 
the  sound  produced  by  blowing  through  a  tube;  they  are  sometimes 
cooing,  sighing,  or  moaning  in  character.  Their  intensity  varies  from 
a  sound  which  can  be  scarcely  recognized  to  one  which  may  be  heard  at 


ADVENTITIOUS  SOUNDS. 


49 


a  distance  from  the  chest,  and  their  pitch  is  always  low.  They  may  be 
heard  during  both  inspiration  and  expiration,  but  are  most  frequent  in 
expiration.  They  are  produced  in  bronchial  tubes  exceeding  one-eighth 
of  an  inch  in  diameter.  They  are  caused  by  the  vibrations  of  viscid 
mucus  or  by  a  fold  of  mucous  membrane,  or  by  anything  which  con- 
stricts the  calibre  of  the  tube,  as  pressure  upon  its  external  surface  by 
tumors,  bands  of  cicatricial  tissue  resulting  from  former  diseases,  or 
contraction  of  the  circular  muscular  fibres  causing  a  uniform  narrowing 
of  the  tube  (Fig.  1?).  These  sounds  are  not  removed  by  coughing,  un- 
less caused  by  tenacious  mucus  adhering  to  the  side  of  the  bronchial 
tube.  Though  in  the  great  majority  of  instances  after  coughing  or 
after  deep  inspiration  an  individual  rale  may  disappear,  other  rales  will 
remain  in  some  portion  of  the  chest.     This  sign  is  obtained  in  greatest 


Subcrepitant  rales 


Mucous  rales. 


7  Sonorous  rales 


K  Sibilant  rales. 


Crepitant  rales. 
Fig.  17.— Bronchial  Rales,  Dry  and  Moist,  and  Subcrepitant  Rales. 


perfection  in  the  early  stages  of  acute  bronchitis  and  in  asthma.  It  is 
also  heard  in  some  cases  of  chronic  bronchitis,  occasionally  in  phthisis, 
and  rarely  in  jmeumonia,  being  in  these  latter  instances  associated  with 
other  adventitious  sounds. 

When  obtained  in  phthisis,  the  dry  rales  are  few  in  number  and  are 
associated  with  moist  rales. 

In  the  early  stage  of  asthma,  sonorous  rales  may  be  heard  in  great 
numbers  over  the  entire  chest. 

Sibilant  rales  occur  both  in  inspiration  and  in  expiration,  but  are 
heard  mostly  in  inspiration.  They  are  not  so  intense  as  the  sonorous 
sounds.  Their  pitch  is  high,  and  in  quality  they  vary  almost  as  much 
as  sonorous  rales,  being  sometimes  whistling,  sometimes  hissing,  and 
sometimes  almost  creaking.  They  are  caused  in  the  smaller  bronchial 
tubes  by  the  same  conditions  which  give  rise  to  rales  in  the  larger  bron- 
chi (Fig.  17). 

They  are  heard  most  frequently  and  abundantly  in  asthma  and  in 
4 


50  PHYSICAL  DIAGNOSIS. 

capillary  bronchitis.     In  ordinary  acute  bronchitis  they  may  be  heard, 
though  in  limited  numbers. 

Sibilant  rales  are  heard  occasionally  in  phthisis,  due  then  to  localized  bron- 
chitis or  to  tubercular  deposits.  They  are  sometimes,  though  not  often,  heard 
in  pneumonia.  Occasionally,  even  in  healthy  or  apparently  healthy  chests,  we 
may  hear  two  or  three  of  these  fine  sounds  near  tbe  borders  of  the  lungs. 

Sibilant  rales  may  be  altered,  but  they  are  seldom  removed*by  cough- 
ing or  by  forced  inspiration. 

Moist  rales  are  grouped  as  mucous,  large  and  small,  subcrepitant 
and  crepitant,  according  to  their  characteristics. 

Mucous  rales,  also  produced  in  the  bronchial  tubes,  are  large  or  small 
according  to  the  size  of  the  tubes,  and  are  caused  by  air  bubbling 
through  fluid — mucus,  pus,  serum,  or  blood  (Fig.  17).  If  the  bubbling 
happen  to  be  in  a  large  bronchus,  we  get  a  large,  coarse,  mucous  rale; 
if  in  a  smaller  bronchus,  the  rale  is  much  finer. 

These  rales  are  heard  during  both  inspiration  and  expiration,  and 
vary  greatly  in  intensity.  Sometimes,  like  sonorous  rales,  they  may  be 
heard  at  a  distance  from  the  chest ;  they  are  at  other  times  hardly  audi- 
ble. Their  pitch  depends  upon  the  condition  of  the  surrounding  lung 
tissue.  In  simple  inflammation  of  the  mucous  membrane,  the  rales  are 
low  pitched;  but  when  consolidation  surrounds  the  bronchial  tubes,  as 
in  pneumonia  and  in  phthisis,  the  pitch  is  high.  These  sounds  are  ob- 
tained in  greatest  perfection  in  chronic  brunch  if  is,  but  may  be  heard 
in  acute  bronchitis  after  the  dry  stage  has  passed.  They  are  present 
in  greater  or  less  degree  in  nearly  all  cases  of  consumption,  in  the  third 
stage  of  pneumonia,  and  in  pulmonary  oedema,  and  are  numerous  when 
hemorrhage  has  taken  place  into  the  bronchial  tubes  until  coagulation 
occurs.  In  phthisis  they  are  found  over  a  limited  space,  due  some- 
times to  associated  bronchitis,  at  other  times  to  the  escape  of  fluid  from 
a  cavity  into  the  bronchial  tubes.  These,  unlike  dry  rales,  are  usually 
much  affected  by  deep  inspiration  and  coughing,  by  which  they  may 
be  considerably  altered  or  entirely  removed. 

Subcrepitant  rales  are  moist  sounds,  which  are  produced  in  the  very 
fine  bronchial  tubes,  probably  in  the  ultimate  bronchi  and  those  a  size 
larger  (Fig.  IT).  They  are  caused  by  air  bubbling  through  fluid,  and 
may  be  heard  during  either  or  both  portions  of  the  respiratory  act,  but 
are  most  frequently  heard  with  inspiration.  They  are  of  comparatively 
feeble  intensity,  vary  in  pitch  according  to  the  condition  of  the  surround- 
ing tissue,  and  are  distinctly  moist  and  crepitating  or  crackling  in 
quality. 

These  rales  may  be  heard  most  perfectly  in  capillary  bronchitis  and 
the  third  stage  of  pneumonia.  They  are  often  found  in  asthma  shortly 
after  the  paroxysm.  They  are  present  in  congestion  of  the  lung,  puru- 
lent bronchitis,  and  pulmonary  oedema,  and  are  found  over  a  limited  por- 


ADVENTITIOUS  SOUNDS.  51 

tion  of  the  lung  in  many  cases  of  phthisis.  They  occur  in  brown  indu- 
ration of  the  lungs,  and  are  heard  after  hemorrhage  into  the  smaller 
bronchial  tubes,  limited  to  the  position  of  the  hemorrhage. 

The  subcrepitant  rale,  due  to  circumscribed  capillary  bronchitis,  is 
a  sign  of  great  value  in  the  early  diagnosis  of  phthisis,  in  which  it  may 
often  be  found  at  the  apex  of  the  lung  before  any  other  signs  can  be 
detected. 

The  crepitant  rale  is  largely  like  the  subcrepitant,  but  differs  from 
the  latter  in  two  respects :  it  is  not  so  moist  or  liquid  in  character,  so 
that  it  is  sometimes  classed  as  a  dry  rale;  and  it  is  never  obtained  in 
expiration.  Crepitant  rales  are  very  well  imitated  by  rubbing  together 
a  lock  of  hair  close  to  the  ear.  They  were  compared  by  Laennec  to  the 
sound  produced  by  throwing  salt  upon  a  fire. 

These  rales  are  produced  in  the  vesicles,  intercellular  spaces,  and 
ultimate  bronchi  (Fig.  17).  There  are  two  hypotheses  as  to  their 
mode  of  production:  one  is  that  they  are  caused  by  air  bubbling 
through  fluid  within  the  air  vesicle,  just  as  mucous  rales  are  produced 
in  the  bronchial  tubes;  the  other,  that  they  are  due  to  the  separation  of 
the  agglutinated  surfaces  of  the  capillary  tubes  or  of  the  air  vesicles. 
Which  of  these  is  true,  or  whether  both  are  in  part  correct,  has  not  been 
decided.  To  me  they  seem  to  be  produced  by  separation  of  the  sticky 
surfaces  of  the  air  vesicles,  and  the  capillary  bronchi.  In  some  cases  of 
pneumonia,  for  instance  when  associated  with  inflammatory  rheumatism, 
no  crepitant  rale  can  be  obtained  which  may  be  accounted  for  by  slight 
viscidity  of  the  inflammatory  lymph;  for  if  the  sounds  were  produced 
by  air  bubbling  through  fluid,  they  would  occur  regardless  of  the  nature 
of  that  fluid. 

Crepitant  rales  are  much  more  numerous  than  the  subcrepitant.  In  listen- 
ing to  subcrepitant  rales,  we  seldom  seem  to  hear  more  than  ten  or  fifteen  at 
once  ;  whereas  with  the  crepitant  rale  we  seem  to  hear  a  hundred  or  more  with 
each  inspiration. 

Crepitant  rales  are  obtained  in  perfection  in  the  early  stage  of  pneu- 
monia, of  which  they  are  considered  diagnostic.  This  stage  lasts  but  a 
few  hours;  consequently  in  many  cases  of  inflammation  of  the  lung  the 
rales  have  disappeared  before  we  see  the  patient. 

A  few  crepitant  rales  are  sometimes  heard  in  congestion  of  the  lung 
and  in  pulmonary  oedema,  and  they  are  frequently  found  in  phthisis, 
in  a  small  zone  around  the  consolidation.  In  this  latter  case  they  seem 
to  result  from  gradual  extension  of  the  pneumonitis,  which  often  pre- 
cedes tubercular  deposit. 

Crepitant  rales,  subcrepitant  rales,  and  friction  sounds  are  sometimes 
so  much  alike  that  it  is  difficult  to  distinguish  between  them.  If  dry 
crepitating  sounds  are  numerous  and  heard  only  on  inspiration,  they 
are  crepitant  rales;  but  if  dry  crepitating  sounds  are  few  in  number  and 


52  PHYSICAL  DIAGNOSIS. 

are  heard  in  expiration  or  iu  both  inspiration  and  expiration,  they  are 
likely  to  be  friction  sounds.  Subcrepitant  rales  are  more  moist  and  not 
nearly  so  numerous  as  crepitant  rales,  and  they  are  usually  heard  in  both 
inspiration  and  expiration.  The  moist  character,  the  number,  and  the  time 
of  occurrence  of  subcrepitant  rales  will  enable  us  to  distinguish  them 
from  the  crepitant;  and  their  deeper  seat  and  their  constancy  will  usu- 
ally enable  us  to  distinguish  them  from  fine  friction  sounds — which  are 
still  fewer  in  number — even  when  the  latter  are  moist  in  character. 

Crepitant  rales  are  not  much  affected  by  cough  or  forced  respiration 
when  due  to  pneumonia,  but  in  other  instances  two  or  three  full  inspi- 
rations will  frequently  dispel  them. 

Exceptional. — Either  crepitant  or  subcrepitant  rales  may  be  sometimes 
brought  out  directly  after  coughing  where  they  were  absent  a  moment  pre- 
viously. A  sound  closely  i*esembling  the  subcrepitant  or  the  crepitant  rale  may 
frequently  be  obtained  over  the  thin  border  of  the  healthy  lung  ;  in  these  in- 
stances, only  a  few  of  the  rales  are  heard,  and  they  disappear  after  three  or  four 
forced  inspirations. 

Gurgles  resemble  large  mucous  rales,  but  are  generally  higher  in 
pitch  and  possess  a  hollow  metallic  quality;  though  occurring  during 
both  portions  of  the  respiratory  act,  they  are  most  frequent  in  inspira- 
tion. They  are  produced  by  air  bubbling  through  fluid  in  cavities  which 
communicate  with  the  bronchial  tubes  (Fig.  16).  If  cavities  are  com- 
pletely filled  with  fluid  or  entirely  empty,  or  if  the  level  of  the  fluid 
does  not  reach  above  the  opening  of  the  bronchial  tube,  no  gurgles  will 
be  produced.  These  sounds  are  large  or  small,  according  to  the  size  of 
the  cavity  in  which  they  are  produced. 

This  sign  is  usually  indicative  of  phthisis,  but  may  occur  in  any  pul- 
monary disease  which  causes  excavations. 

The  mucous  click  resembles  an  isolated  subcrepitant  rale,  and  is 
heard  during  inspiration  only.  The  sign  generally  consists  of  a  single 
click,  or,  at  most,  of  two  or  three  clicks.  It  is  a  sharp  crackling  or 
clicking  sound,  supposed  to  be  produced  in  the  smaller  bronchial  tubes 
by  sudden  separation  of  their  agglutinated  surfaces  during  inspiration; 
it  is  not  usually  affected  by  cough.  When  heard  over  the  apex  of  one 
lung,  it  is  a  sign  of  considerable  value  in  the  early  diagnosis  of  phthisis. 
Such  sounds  are  sometimes  heard  over  a  considerable  portion  of  the 
lung  in  acute  tuberculosis,  in  extensive  chronic  pneumonia,  or  in  the  later 
stages  of  interstitial  or  catarrhal  pneumonia. 

Friction  Sounds. — Friction  sounds  are  produced  by  rubbing  to- 
gether of  the  two  pleural  surfaces,  which  are  either  dry  from  diminu- 
tion of  their  natural  secretions  or  roughened  by  exudation  of  inflamma- 
tory lymph  (Fig.  18).  These  sounds  are  grazing,  rubbing,  grating,  rasp- 
ing, or  creaking  in  character;  sometimes  dry,  sometimes  moist.  They 
may  be  simulated  by  rubbing  the  back  of  the  hand,  while  listening  with 
the  stethoscope  on  its  palm,  or  by  rubbing  the  fingers  on  the  integument 


ADVENTITIOUS  SOUNDS. 


53 


when  auscultating  the  chest.  They  are  usually  few  in  number  and 
transitory,  being  heard  for  a  few  respirations,  and  then  disappearing  to 
return  again  in  a  few  minutes;  they  may  be  heard  just  at  the  end  of 
inspiration  or  at  the  beginning  of  expiration.  This  is  the  characteristic 
sign  of  pleurisy.  The  grazing  friction  sound  is  only  heard  in  the  be- 
ginning of  the  inflammation,  and  can  be  detected  most  frequently  in  the 
circumscribed  pleurisy  accompanying  phthisis.  Some  one  of  the  other 
varieties,  of  which  the  quality  is  of  no  importance,  may  be  heard  in  the 
first  and  third  stages  of  pleurisy.  Care  must  always  be  taken  not  to  mis- 
take for  this  sign  the  sounds  produced  by  crackling  of  the  hairs  beneath 
the  instrument,  or  by  the  rubbing  of  the  stethoscope,  the  fingers,  or  the 


Friction.— — 


Deficient  respiratory        | 
murmur  and  dulness.    ) 


Flatness  ;  loss  of    ) 
respiratory  sounds,  j" 


Fig.  18.— Acute  Pleurisy.  The  upper  part  of  the  lung  is  in  a  normal  condition,  or  the  air  cells 
are  slightly  distended.  The  lower  part  of  the  lung  is  partially  collapsed.  The  upper  surface  of  the 
fluid  is  not  horizontal,  but  it  conforms  more  or  less  perfectly  to  the  natural  outline  of  the  lung. 


clothing  on  the  surface,  or  of  the  clothing  or  fingers  on  the  instrument. 
Sounds  closely  resembling  the  friction  murmur  are  often  heard  over  the 
false  ribs  in  a  healthy  chest.  They  seem  to  be  produced  by  slight 
movements  of  the  skin  beneath  the  rim  of  the  stethoscope. 

Creaking  or  crumpling  sounds  are  sometimes  obtained  over  the  chest, 
the  signification  of  which  is  not  fully  understood.  The  creaking  sounds 
are  most  frequently  heard  at  the  lower  part  of  the  thorax,  and  are  sup- 
posed to  be  due  to  old  pleuritic  adhesions.  Both  creaking  or  crackling 
and  crumpling  sounds  are  sometimes  obtained  over  the  upper  portion 
of  the  chest.  The  crumpling  sounds  which  are  heard  in  inspiration  re- 
semble those  which  may  be  produced  by  inflating  a  dried  bladder,  and 
are  supposed  to  be  produced  from  similar  causes;  that  is,  the  inflation 


54  PHYSICAL  DIAGNOSIS. 

of  dry  emphysematous  air  cells.  Thompson  considers  these  sounds  in- 
dicative of  syphilitic  disease  of  the  lungs.  "When  confined  to  the  apex, 
they  are  nearly  always  associated  with  phthisis. 

Metallic  tinkling  is  a  clear,  silvery,  tinkling  sound,  like  that  pro- 
duced by  dropping  a  pin  into  a  glass.  It  seems  to  be  caused  by  the 
falling  of  a  drop  of  fluid  from  the  upper  part  of  a  large  cavity  on  the 
surface  of  fluid  below.  It  can  sometimes  be  heard  over  one  entire  side, 
but  it  is  usually  most  distinct  on  a  level  with  the  nipple.  "When  the 
proper  conditions  are  present  within  the  chest — that  is,  a  large  cavity 
containing  air  and  fluid — it  may  be  produced  by  any  agitation,  such,  for 
example,  as  speaking,  coughing,  deep  inspiration,  or  occasionally  by  the 
act  of  swallowing.  The  sign  occurs  most  frequently  in  the  pleural  cav- 
itv  in  pneumo-hydrothorax;  but  in  exceptional  instances  it  is  produced 
in  very  large  pulmonary  cavities.  A  sound  very  similar  to  this  may 
sometimes  be  heard  over  the  stomach  when  distended  with  gas. 

VOCAL   SOUNDS. 

Considerable  information  regarding  the  condition  of  the  lungs  can 
be  obtained  by  studying  the  sounds  of  the  voice  as  transmitted  through 
the  chest  walls. 

If  we  listen  over  the  healthy  chest  while  the  person  is  sjieaking,  an 
indistinct,  distant,  and  muffled  sound  will  be  heard,  termed  normal  vocal 
resonance.  It  is  due  to  the  fact  that  sounds  produced  in  the  larynx  are 
transmitted  not  only  outward  through  the  mouth,  but  also  downward 
through  every  branch  of  the  bronchial  tree.  Vocal  resonance,  like  most 
of  the  other  pulmonary  sounds,  varies  greatly  in  different  healthy  indi- 
viduals and  fti  different  portions  of  the  same  chest.  If  a  person  has  a 
low-pitched  intense  voice,  the  vocal  resonance  will  be  more  forcible  than 
in  those  who  have  high-pitched  or  feeble  voices. 

In  studying  the  voice-sounds  by  immediate  auscultation,  it  is  desira- 
ble to  close  the  ear  which  is  not  applied  to  the  chest,  in  order  to  exclude 
sounds  coming  from  the  mouth,  and  it  is  better  to  have  the  patient 
count  one,  two,  three,  than  to  ask  him  questions  and  listen  for  the  an- 
swers. By  the  latter  course  the  examiner's  attention  is  distracted  from 
the  sounds  within  the  chest  in  the  attempt  to  catch  the  patient's  reply. 
The  varieties  of  vocal  resonance  which  may  be  heard  over  different  re- 
gions of  the  normal  chest  are  named  from  the  parts  in  which  they  are 
produced;  over  the  larynx  and  trachea  we  have  laryngeal  and  tracheal 
resonance;  over  the  bronchial  tubes,  bronchial  resonance;  and  over  air 
vesicles,  the  normal  vesicular  or,  as  it  is  usually  termed,  normal  vocal 
resonance. 

Laryngophony  is  the  vocal  resonance  obtained  over  the  larynx,  and 
tracheophony  that  obtained  over  the  trachea.  In  these  varieties  the 
words  are  imperfectly  articulated,  but  the  voice  is  transmitted  to  the 
ear  "  with  a  force  and  intensity  almost  painful."     The  sounds  are  con- 


VOCAL  SOUNDS.  55 

centrated  or,  in  other  words,  seem  to  be  produced  within  a  small  area 
immediately  beneath  the  stethoscope,  and  necessarily  vary  in  pitch  with 
the  pitch  of  the  individual's  voice. 

Normal  bronchophony  is  obtained  while  the  person  is  speaking, 
by  listening  over  the  bronchial  tubes,  near  the  border  of  the  sternum 
from  the  first  to  the  third  rib,  or  more  especially  directly  over  the  main 
bronchi  on  a  level  with  the  second  costal  cartilages  in  front,  or  on  a  level 
with  the  fourth  dorsal  vertebra  in  the  inter-scapular  region.  This 
occupies  a  position  midway  between  normal  vocal  resonance  and  laryn- 
gophony.  The  sounds  thus  obtained  are  transmitted  to  the  ear  with 
considerable  intensity,  though  with  much  less  force  than  over  the  larynx; 
they  appear  to  be  produced  immediately  beneath  the  stethoscope,  but 
the  words  seem  very  imperfectly  articulated.  Whenever  this  sign  is  ob- 
tained over  any  other  portion  of  the  chest,  it  indicates  consolidation  of 
the  pulmonary  parenchyma. 

Normal  vocal  resonance  is  obtained  by  listening  to  the  voice  over 
the  vesicular  portions  of  the  lung.  This  sound,  having  no  approach  to 
articulation,  is  distant  and  diffused,  seeming  to  come  from  the  deeper 
portions  of  the  lung  two  or  three  inches  beneath  the  surface.  As  a 
rule,  vocal  resonance  is  always  more  intense  upon  the  right  side  than 
upon  the  left,  especially  in  the  infra-clavicular  regions. 

Exceptional. — In  a  few  instances  over  the  right  apex,  even  in  health,  the 
resonance  very  nearly  approaches  bronchophony.  If  the  sounds  have  this 
character  upon  both  sides,  as  they  have  in  rare  instances,  they  will  be  found 
most  intense  upon  the  right  side,  but  higher  in  pitch  on  the  left — a  disparity 
due  to  the  difference  in  calibre  of  the  bronchial  tubes  ;  those  upon  the  right  side 
being"  the  larger  must  necessarily  give  the  more  intense  and  lower-pitched  sound. 

The  normal  vocal  resonance  is  generally  obtained  over  the  entire  chest 
in  men,  but  only  over  the  upper  part  in  women  and  children,  in  whom 
it  is  a  sign  of  little  value. 

This  sign  is  modified  by  disease,  principally  in  its  intensity,  which 
*riay  be  either  diminished  or  increased. 


Diminished.       ■{  Vocal  sounds  feeble  or  suppressed. 


CO      J 

a 


r  Vocal  sounds  exaggerated. 
Resonance  which  is  termed  bronchophony. 
Increased.  <  "  ■  "  "       asgophony. 

"  "  "       pectoriloquy. 

[  "  "  "       amphoric  voice. 


Diminished  Kesonance. — Diminished  resonance  is  usually  due  to 
much  the  same  causes  as  the  diminished  respiratory  murmur;, that  is,, 
separation  of  the  pulmonary  from  the  costal  pleura  by  air  or  fluid,  as  in 
pneumothorax  or  pleurisy.  It  also  occurs  in  cases  of  extreme  emphysema, 
in  pulmonary  oedema,  in  bronchitis  with  free  secretion,  and  occasionally 
where  there  is  extreme  pulmonary  consolidation. 


56  PHYSICAL  DIAGNOSIS. 

The  vocal  sounds  are  mostly  suppressed  over  fluid  in  the  pleural  sac; 
but  just  above  the  level  of  the  fluid  the  air  cells  are  partially  collapsed, 
so  that  vocal  resonance  is  increased.  For  an  inch  or  an  inch  and  a  half 
below  the  level  of  the  fluid  the  resonance  is  diminished  in  intensity,  and 
a  little  lower  it  is  nearly  suppressed.  Thus  we  are  able  to  ascertain 
the  height  of  the  fluid  by  means  of  the  vocal  resonance  as  well  as  by 
percussion. 

This  sign  is  principally  of  value  in  the  diagnosis  of  pleuritic  effusion, 
by  enabling  us  to  distinguish  between  it  and  consolidation  of  the  lower 
part  of  the  lung. 

Exceptional — In  some  cases  the  vocai  resonance  may  be  heard  distinctly  all 
over  the  pleuritic  effusion,  though  the  sounds  are  distant  and  more  or  less  muffled. 

Increased  Vocal  Kesonance. — Exaggerated  vocal  resonance  differs 
from  the  normal  voice-sounds  simrdy  in  its  intensity.  This  sign  de- 
notes more  or  less  consolidation  of  the  lung  tissue  or  collapse  of  the  air 
vesicles,  and  is  usually  associated  with  broncho-vesicular  respiration. 

It  is  a  sign  of  considerable  importance  in  the  diagnosis  of  the  early 
stage  of  phthisis  and  in  discriminating  between  pneumonia  and  pleurisy. 

Exceptional. — In  very  rare  cases  the  vocal  resonance  is  exaggerated  in  pneu- 
mothorax and  in  emphysema. 

Bronchophony,  as  already  noted,  consists  of  more  or  less  intense  vocal 
sounds,  usually  imperfectly  articulated,  which  have  a  peculiar  degree  of 
concentration,  or,  in  other  words,  seem  to  be  produced  immediately  be- 
neath the  stethoscope,  instead  of  coming  from  the  deeper  portions  of 
the  lung.  The  intensity  of  this  sign,  which  may  be  greater  or  less  than 
that  of  normal  resonance,  is  an  unimportant  element;  so  also  is  the  dis- 
tinctness of  articulation.  Its  recognition  depends  chiefly  on  the  charac- 
teristic concentration. 

The  significance  of  bronchophony  depends  upon  its  location.  If 
heard  over  the  main  bronchial  tubes,  it  may  be  simply  a  healthy  sound; 
but  if  heard  over  vesicular  portions  of  the  lungs,  it  is  indicative  of 
consolidation.  It  is  usually  associated  with  a  tubular  respiratory  mur- 
mur; but  as  it  occurs  with  a  less  amount  of  consolidation  than  is  neces- 
sary for  true  bronchial  breathing,  it  may  frequently  be  obtained  with 
broncho-vesicular  respiration. 

Exceptional. — Bronchophony  usually  possesses  the  characteristic  concentra- 
tion ;  but  when  the  consolidated  lung  is  separated  from  the  chest  wall  by  fluid, 
ft  may  sound  distant. 

This  sign  is  of  special  value  in  the  diagnosis  of  the  second  stage  of 
pneumonia  (Fig.  27).  It  is  seldom  obtained  perfectly  in  phthisis, 
because  in  this  disease  consolidation  is  not  usually  complete. 

Exceptional. — Bronchophony  is  occasionally  obtained  in  carcinoma  of  the 
lung,  though  usually  tins  disease  involves  the  whole  tissue,  air  vesicles  and  bron- 


VOCAL  SOUJJ-DS.  57 

chial  tubes  alike,  or  it  crowds  the  pulmonary  tissue  before  it,  thus  hindering  the 
transmission  of  the  voice.  But  when  the  air  vesicles  alone  are  filled  and  the 
bronchial  tubes  remain  patent,  as  occurs  in  rare  cases,  br-onchophony  may  be  ob- 
tained. It  is  also  present  in  hemorrhagic  infarctions  which  fill  the  air  vesicles 
but  leave  the  bronchial  tubes  open,  and  may  therefore  be  a  sign  in  pulmonary 
apoplexy. 

^Egophony  is  a  variety  of  bronchophony.  It  is  a  tremulous  sound 
which  has  been  compared  to  the  bleating  of  a  goat;  hence  the  name. 
Like  bronchophony,  it  conveys  to  the  listening  ear  the  impression  of 
having  been  produced  within  a  very  limited  portion  of  the  lung;  unlike 
the  latter,  it  seems  to  come  up  from  a  considerable  depth,  and  to  trem- 
ble about  the  end  of  the  stethoscope.  When  present,  it  may  be  most 
readily  obtained  in  the  inter-scapular  or  axillary  regions.  This  sound 
is  generally  produced  in  consolidated  lung  tissue  which  is  separated 
from  the  chest  wall  by  a  thin  layer  of  fluid.  It  is  a  sign  of  pleuro-yneu- 
monia — that  is,  pneumonia  and  pleurisy  with  effusion ;  but  even  in  this 
disease  it  is  present  only  a  short  time,  and  is  a  sign  of  little  value. 
zEgophony  is  most  frequently  produced  when  the  pleural  cavity  is  about 
half  filled  with  fluid. 

In  ordinary  pleuritic  effusions,  the  lung  just  above  the  surface  of  the 
fluid  is  more  or  less  solidified  by  collapse  of  a  portion  of  the  air  vesicles; 
under  such  circumstances  segophony  may  be  produced  providing  the 
pleura-pulmonalis  and  the  pleura-costalis  are  agglutinated  just  above 
the  collapsed  lung. 

Pectoriloquy  differs  from  bronchophony  in  that  the  articulated 
speech  is  more  completely  transmitted.  In  bronchophony  the  voice  is 
heard,  but  the  words  are  not  distinct.  In  pectoriloquy  articulation  is 
nearly  perfect.  There  are  two  varieties  of  pectoriloquy :  one  in  which 
the  sounds  are  concentrated  and  near  the  ear  like  bronchophony,  but 
are  heard  over  a  considerable  portion  of  the  lung;  and  another  in  which 
the  ^ign  is  confined  to  a  limited  space  and  has  not  the  degree  of  concen- 
tration found  in  bronchophony.  The  first  of  these,  which  is  high  in 
pitch  and  clanging  or  metallic  in  quality,  is  frequently  produced  by  sim- 
ple consolidation  of  lung  tissue.  The  second,  which  is  low  in  pitch  and 
softer  in  quality,  is  always  a  trustworthy  sign  of  a  pulmonary  cavity 
with  smooth  walls  and  a  large  opening  into  a  bronchial  tube.  Well- 
defined  pectoriloquy  is  not  a  frequent  sign,  but  when  heard  the  first 
variety  is  a  sign  of  phthisis  or  pneumonia,  and  the  second  of  any  of  those 
diseases  which  cause  vomica?,  viz.,  phthisis,  pulmonary  abscess  or  gan- 
grene, and  bronchiectasis. 

Amphoric  voice  is  hollow  and  more  or  less  musical  in  character. 
The  musical  quality  follows  the  voice  and  is  termed  the  amphoric  echo. 
The  words  are  not  articulated,  as  in  pectoriloquy.  This  sign  occurs 
under  the  same  conditions  as  amphoric  respiration  and  amphoric  per- 
cussion resonance;  that  is,  over  the  pleural  sac  when  containing  air  and 


58  PHYSICAL  DIAGNOSIS. 

communicating  freely  with  a  bronchial  tube,  and  over  very  large  cavities 
in  the  lungs. 

Exceptional. — There  are  good  reasons  for  believing  that,  in  rare  cases,  am- 
phoric voice,  as  well  as  amphoric  respiration,  may  be  heard  over  a  layer  of  air 
in  the  pleural  cavity  which  does  not  communicate  with  the  bronchial  tubes. 

Amphoric  voice  is  a  sign  of  pneumo-hydrothorax,  in  which  disease  it 
is  associated  with  tympanitic  resonance  over  the  upper  part  of  the  chest, 
and  ordinarily  with  the  succussion  sound.  If  the  latter  signs  are  absent, 
the  amphoric  voice  is  probably  produced  in  a  phthisical  cavity. 

"Whispering  Vocal  Resonance. — Flint  described  the  whisper  reso- 
nance with  considerable  minuteness.  He  considered  the  signs  which  it 
furnishes  of  equal  value  Avith  those  from  a  loud  voice;  I  find  them  of 
even  greater  importance. 

The  normal  bronchial  whisper  is  a  term  applied  to  sounds  of 
a  blowing  or  tubular  character,  very  closely  resembling  the  sound  of 
forced  respiration,  heard  in  listening  over  the  upper  portion  of  the  chest 
when  a  person  is  speaking  in  a  sharp  whisper.  Its  modifications  by 
disease  are  classified  as  exaggerated  bronchial  whisper,  whispering  bron- 
chophony, cavernous  whisper,  whispering  pectoriloquy,  and  amphoric 
whisper. 

Exaggerated  bronchial  whisper  is  more  intense  and  higher  in 
pitch  than  the  normal  sound.  It  is  produced  in  lungs  which  are  slightly 
solidified. 

Whispering  bronchophony  is  higher  in  pitch  and  more  intense 
and  blowing  than  the  preceding.  It  has  the  same  characteristic  concen- 
tration and  nearness  to  the  ear  as  bronchophony  with  the  loud  voice. 
It  may  be  obtained  over  lungs  so  slightly  solidified  as  to  yield  only  ex- 
aggerated vocal  resonance  when  the  patient  is  speaking  aloud;  therefore 
it  can  be  appreciated  sooner  than  bronchophony  with  the  loud  voice. 
This  fact  renders  whispering  bronchophony  a  most  important  sign  in 
the  early  stage  of  jmthisis. 

The  cavernous  whisper  is  a  low-pitched,  blowing  sound,  confined 
to  a  limited  portion  of  the  chest.  It  is  produced  within  pulmonary 
cavities  under  the  same  conditions  as  cavernous  respiration.  This  sign 
is  principally  of  value  in  the  diagnosis  of  phthisis. 

Whispering  pectoriloquy  differs  from  whispering  bronchophony 
only  in  its  more  perfect  articulation.  When  obtained  over  a  small  space 
only,  this  is  a  sign  of  a  cavity.     It  is  most  frequently  found  in  phthisis. 

Amphoric  whisper  occurs  under  the  same  conditions  as  the  am- 
phoric voice  or  amphoric  resonance  on  percussion;  that  is,  over  the 
pleural  sac  filled  with  air,  or  over  very  large  cavities  in  the  lung  tissue. 

Aphonic  pectoriloquy  is  a  term  which  has  been  applied  to  the  voice  sounds 
when  the  patient  is  speaking  in  a  low  tone.  It  has  been  stated  that  these 
sounds  can  be  distinctly  heard  not  only  over  consolidated  or  collapsed  lung, 


TUSSIVE  SIGNS.  59 

but  also  even  when  the  organ  in  this  condition  is  separated  from  the  thoracic 
■wall  by  a  collection  of  air  or  serum- ;  however,  these  vibrations  are  not  conducted 
through  %)us.  By  studying  this  variety  of  vocal  resonance,  it  is  claimed  that  we 
may  determine  whether  pleural  effusions  are  of  a  serous  or  of  a  purulent 
character.    I  have  been  able  to  verify  this  statement  in  a  few  cases,  but  not  in  all. 

Tussive  Sigxs. — The  resonance  of  cough  may  sometimes  be  studied 
with  advantage,  especially  in  children.  The  act  of  coughing  is  often  of 
special  value  in  dislodging  obstructions  in  the  bronchial  tubes  or  pul- 
monary cavities,  and  also  in  causing  a  subsequent  deep  inspiration  which 
will  freely  inflate  the  air  cells,  thus  bringing  out  signs  which  might 
otherwise  be  overlooked.  The  different  varieties  of  cough  are  classified 
as  laryngeal,  bronchial,  cavernous,  and  amphoric. 

Laryngeal  cough  is  usually  more  or  less  hacking  in  charac- 
ter, and  often  spasmodic.     It  is  indicative  of  laryngitis. 

Beoxchial  cough  is  quick,  harsh,  and  brassy.  It  is  accompanied 
by  a  thrill  or  fremitus,  and  if  severe  is  nearly  always  attended  with  pain 
beneath  the  sternum  or  along  the  inferior  ribs,  corresponding  to  the 
attachment  of  the  diaphragm.     It  is  generally  indicative  of  bronchitis. 

Caveexous  cough  is  produced  under  the  same  circumstances  as 
cavernous  respiration,  and  is  generally  associated  with  gurgles.  It  has 
a  hollow  quality  and  is  usually  very  intense. 

Amphoric  cough  is  more  musical  and  hollow  in  quality,  is  generally 
lower  in  pitch,  and  seems  to  penetrate  the  ear  with  less  force  than  the 
cavernous.  It  is  heard  over  very  large  pulmonary  cavities  or  over  the 
pleura  when  filled  with  air. 

Sometimes  large  pulmonary  cavities  are  traversed  by  trabecule  which 
yield  a  peculiar  twang  when  the  patient  coughs.  This  is  of  special 
value,  as  these  strings  prevent  cavernous  or  amphoric  voice-sounds. 

Tussive  signs  are  usually,  though  not  always,  transmitted  through 
consolidated  lung,  but  seldom  through  collections  of  fluid. 

TTe  may  obtain  considerable  information  about  the  condition  of  the 
lungs  in  children  who  cannot  be  induced  to  speak  by  studying  the  cry, 
which  is  subject  to  the  same  variations  as  vocal  resonance  in  adults. 


CHAPTER  V. 

PULMONARY   DISEASES. 
PLEURISY   OR  PLEURITIS. 

Pleurisy  consists  of  an  inflammation,  more  or  less  extensive,  of  the 
serous  membrane  covering  the  lungs  and  lining  the  thoracic  walls. 
There  are  three  recognized  varieties  of  this  disease:  the  acute,  subacute, 
and  chronic  or  suppurative,  also  called  empyema. 

Anatomical  and  Pathological  Characteristics. — There  is  first 
hyperemia  and  reddening  of  the  pleura  with  dryness  from  checking  of 
its  normal  secretion,  there  is  swelling  from  transudation  of  serum  into  the 
perivascular  spaces,  and  multiplication  of  connective-tissue  cells  with 
loss  of  the  normal  glistening  of  the  pleural  surface  due  to  degeneration 
and  exfoliation  of  superficial  endothelial  cells.  Then  follow  exudation 
of  inflammatory  lymph  and  effusion  of  serum  to  a  greater  or  less  extent; 
the  former  clinging  to  the  pleural  surface  presents  a  rough,  shaggy 
appearance ;  the  latter  gravitating  to  the  lowest  part  of  the  pleural  sac, 
usually  holds  in  suspension  shreds  of  fibrin,  leucocytes,  and  endothelial 
cells.  Thickening  of  the  serous  membrane  results  from  multiplication, 
in  it  and  in  the  fibrous  exudate,  of  new  connective-tissue  cells;  these 
mature,  new  blood-vessels  form,  making  connection  with  the  original 
vessels  of  the  pleura,  and  organization  of  the  exudate  is  the  result. 

Adhesions  more  or  less  extensive  may  form  between  opposing  pleural 
surfaces,  which  become  bound  together  closely  by  the  plastic  organiza- 
tion, or  more  loosely  by  fibrous  bands  and  false  membranes. 

The  pleural  surface  early  in  the  inflammation  may  present  irregular 
spots  of  ecchymosis  surrounded  by  the  more  diffused  redness;  later, 
whitish  spots  of  fibrous  organization  appear  on  the  free  surface.  The 
effused  serum  is  generally  of  a  light  yellow  or  greenish  color,  has  a 
specific  gravity  of  from  1,010  to  1,024,  contains  four  to  six  per  cent  of 
albumen,  and  coagulates  readily  upon  exposure.  In  these  respects  it 
differs  from  the  fluid  of  hydrothorax,  which  contains  but  one  per  cent  of 
albumen,  its  specific  gravity  being  below  1,015.  The  amount  of  fluid 
varies;  in  acute  pleurisy,  it  is  not  usually  great,  seldom  occupying  more 
than  one-third  or  at  most  one-half  of  the  pleural  sac,  and  is  very  rarely 
sufficient  to  fill  the  cavity.  In  subacute  pleurisy  the  quantity  is  often 
sufficient  to  fill  the  cavity  and  cause  great  distention  of  the  side.  In 
empyema  the  amount  is  seldom  greater  than  in  acute  pleurisy. 


ACUTE  PLEURISY.  61 

The  processes  of  pleuritic  inflammation  vary  with  the  causes  and 
severity  of  the  affection.  The  effusion  takes  its  character  from  the  pres- 
ence of  serum,  fibrin,  endothelial  cells,  blood,  and  pus  in  varying  quantity 
and  variously  combined.  The  products  of  inflammation  in  mild  cases- 
may  be  chiefly  fibrinous  with  little  or  no  serous  effusion;  hence  the  so- 
called  plastic  or  dry  pleurisy.  If  fibrinous  exudate  and  pleural  thick- 
ening are  marked  and  serous  effusion  is  copious,  we  have  the  sero-fibrin- 
ous  form.  If  infective  inflammation  occur  pus  results,  and  we  call  it 
empyema.  The  purulent  accumulation  in  these  cases  swarms  with  the 
characteristic  streptococci  and  staphylococci  of  suppuration,  and  in 
some  instances  the  so-called  diplococci  of  pneumonia  and  bacilli  of 
tuberculosis  may  be  found,  though  they  are  difficult  of  demonstration. 

Hemorrhagic  pleurisy  occasionally  complicates  purpura  hemorrhagica, 
cancer,  scorbutus,  and  tuberculosis,  or  may  result  from  the  lighting  up 
of  a  new  inflammation  in  an  old  pleuritis. 

Serous  pleuritic  effusions  after  remaining  for  a  time  are  usually 
gradually  absorbed,  but  purulent  accumulations  never  to  any  great  ex- 
tent. In  the  latter  the  fluid  tends  to  perforate  the  surrounding  wall 
either  to  appear  externally  or  to  empty  itself  into  an  adjacent  cavity  or 
organ.  The  solid  portion  of  an  effusion  may  be  absorbed  after  under- 
going fatty  metamorphosis,  but  not  infrequently,  sooner  or  later  it  be- 
comes the  seat  of  tubercular  degeneration ;  or  it  may  become  incapsulated 
and  remain  so  for  years;  or  it  may  be  the  seat  of  calcareous  deposition. 
Cases  are  reported  in  which  the  fibrous  exudate  covering  an  entire  lung 
had  been  the  site  of  such  deposit.  Aside  from  these  characteristics  of 
an  inflamed  pleura,  certain  pathological  conditions  result  from  the 
effect  of  the  process  upon  adjacent  structures.  Inflammation  usually 
extends  to  the  lung  tissue  immediately  beneath  the  pleura,  giving  rise 
to  exudation  which  occludes  some  of  the  alveoli.  It  may  also  by  ex- 
tension cause  pericarditis.  The  pleuritic  effusion  may  be  sufficient  to 
cause  complete  collapse  of  the  corresponding  lung. 

The  compressed  lung,  upon  disappearance  of  the  fluid,  tends  slowly  to 
re-expand  unless  pressure  has  been  too  long  continued,  in  which  case  car- 
nification  of  the  organ  results,  and  it  remains  as  a  small,  compact,  leathery 
mass,  a  suitable  nidus  for  subsequent  disease.  Its  complete  expansion 
in  any  case  is  apt  to  be  limited  by  the  formation  of  cicatricial  bands, 
and  the  great  vessels  may  suffer  serious  compression. 

ACUTE    PLEURISY. 

For  convenience  of  description,  acute  pleurisy  has  been  divided  into 
four  stages  by  some  authors:  First,  a  dry  stage;  second,  a  plastic  stage; 
third,  a  stage  of  effusion;  and  fourth,  a  stage  of  absorption.  I  prefer 
the  division  into  three  stages  analogous  to  the  three  stages  of  pneumo- 
nia, calling  the  first  the  dry  stage ;  the  second,  the  stage  of  effusion ;  the 
third,  the  stage  of  absorption. 


G2  PULMONARY  DISEASES. 

Etiology. — Acute  pleurisy  ma}'  be  primary,  or  secondary  to  some 
other  disease. 

Predisposing  Causes. — It  occurs  most  frequently  in  winter  and 
spring,  in  adults  rather  than  children,  and  attacks  preferably  the  male 
sex.     Malnutrition  and  poor  hygienic  conditions  favor  its  occurrence. 

Exciting  Causes. — The  most  common  causes  are  exposure  and  rheu- 
matism.    In  a  weak  person  mental  depression  may  be  an  exciting  cause. 

It  may  result  from  traumatism,  even  of  slight  character.  It  arises 
not  infrequently  from  pneumonia,  phthisis,  pulmonary  infarction,  ab- 
scess, gangrene,  or  tumors;  other  causes  are  found  in  hemorrhage  into 
the  pleural  cavity,  pericarditis,  costal  or  vertebral  caries,  abscess  of  the 
mediastinum,  peritonitis,  and  hydatids  of  the  liver;  also  in  infective  dis- 
eases, Bright's  disease,  pysemia  and  septicaemia. 

Symptomatology. — The  usual  symptoms  of  this  disease  are:  A  sharp, 
cutting  pain  in  the  side,  aggravated  by  general  and  respiratory  move- 
ments; rapid  and  incomplete  inspiration;  a  short,  dry  cough  and  a 
hard,  rapid  pulse,  with  more  or  less  disturbance  of  the  digestive  organs. 
Pain  is  especially  severe  on  inspiration  and  apt  to  be  located  just  be- 
neath the  nipple,  though  in  children  frequently  it  is  less  circumscribed. 
It  is  a  more  constant  symptom  in  adults,  but  variable  in  duration;  it 
usually  diminishes  as  the  general  pyrexia  appears,  or  with  the  occurrence 
of  effusion. 

The  temperature  is  usually  but  slightly  elevated  the  first  day,  99°  or 
100°  F.  in  adults,  but  in  children  102°  or  103°  F.  In  pleuritic  effusion 
of  children,  surface  thermometry  may  reveal  on  the  affected  side  higher 
temperature  by  one  or  two  degrees,  rising  and  falling  with  the  increase 
and  decrease  of  the  effusion.  While  in  very  mild  cases  the  subjective 
symptoms  may  be  so  slight  as  to  attract  little  or  no  attention,  in  rare 
cases  they  may  be  so  severe  as  to  suggest  pneumonia.  Pleuritic  symp- 
toms are  apt  to  be  less  marked  in  the  feeble  and  cachectic.  "When  a 
large  effusion  occurs,  nausea  and  vomiting  are  frequently  present  and 
dyspnoea  becomes  a  prominent  symptom. 

The  most  important  signs  of  pleurisy  are :  short  and  catching  respi- 
ration, friction  fremitus  on  palpation,  and  friction  sounds  heard  on 
auscultation.  Over  the  collection  of  fluid  after  effusion  has  taken  place, 
there  is  flatness  and  loss  of  vocal  fremitus  and  respiratory  murmur.  The 
upper  line  of  flatness  changes  with  the  position  of  the  patient  (Fig.  18). 

In  the  first  stage  we  have  in  the  beginning  simply  dryness  of  the 
pleura,  and  shortly  afterward  an  exudation  of  inflammatory  lymph. 

By  inspection  we  observe  jerking  or  interrupted  and  incomplete  res- 
piration, with  diminution  of  the  expansive  movements  of  the  affected 
side.  This  catching  respiration  results  from  the  patient's  efforts  to 
limit  inspiratory  movement,  in  order  to  prevent  pain.  This  sign, 
though  nearly  always  present,  is  not  diagnostic  of  pleurisy;  for  in  inter- 
costal neuralgia  and  in  pleurodynia  may  be  found  similar  movements. 

If  the  patient  is  sitting  or  in  a  semi-recumbent  position,  his  body 


ACUTE  PLEURISY.  63 

will  be  inclined  toward  the  affected  side.     If  recumbent,  he  is  likely  to 
be  lying  on  the  unaffected  side. 

Occasionally,  especially  in  children,  the  patient's  efforts  to  restrain  the  move- 
ments of  the  affected  side  result  in  temporary  spinal  curvature  toward  that  side. 

On  palpation,  no  signs  will  be  obtained  in  the  early  part  of  this 
stage;  but  a  little  later  friction  fremitus  may  frequently  be  detected, 
and  the  vocal  fremitus  may  be  found  diminished.  Pressure  usually 
elicits  deep-seated  tenderness.     Mensuration  yields  no  additional  signs. 

Percussion  yields  no  signs  at  first;  but  when  plastic  exudation  has 
taken  place,  dulness,  in  proportion  to  the  amount  of  exudation,  will 
be  elicited.  The  dulness  is  always  less  marked  at  the  end  of  forced 
expiration  than  during  normal  respiration. 

Auscultation  early  in  this  stage  discovers  a  feeble  respiratory  mur- 
mur with  jerking  or  cog-wheel  respiration,  and  in  some  instances, 
just  at  the  end  of  inspiration,  a  feeble,  grazing  friction  sound.  When 
plastic  exudation  has  taken  place  the  respiratory  sounds  are  still  more 
feeble,  and  the  friction  sound  becomes  distinct,  on  both  inspiration  and 
expiration,  but  usually  most  intense  with  the  latter.  This  may  have 
any  of  the  characteristics  of  friction  sounds,  as  rubbing,  grazing,  creak- 
ing, or  crackling.  It  may  not  be  obtainable  except  on  cough  or  deep 
■inspiration,  and  will  not  be  heard  if  the  inflammation  is  confined  to  the 
mediastinal  or  diaphragmatic  pleura.  At  this  stage  the  vocal  resonance 
is  somewhat  diminished. 

In  the  second  stage  of  pleurisy  by  inspection  we  still  observe  dimin- 
ished respiratory  movements,  but  not  the  interrupted  respiration  noticed 
in  the  first  stage,  perhaps  also  an  apparent  increase  in  size  of  the 
affected  side ;  but  sufficient  fluid  to  dilate  the  side  of  the  chest  is  excep- 
tional in  acute  pleurisy. 

In  palpation  the  vocal  fremitus  is  absent  over  the  effusion.  Earely, 
distinct  fluctuation  can  be  obtained.  The  apex  beat  of  the  heart  will 
be  found  crowded  to  the  right  or  left,  according  to  the  seat  and  amount 
of  the  effusion.  If  the  pleurisy  is  upon  the  left  side,  the  heart  is 
crowded  to  the  right;  if  upon  the  right  side,  it  is  displaced  in  the  oppo- 
site direction. 

Exceptional. — In  very  rare  instances  of  serous  effusion,  the  vocal  fremitus  is 
not  lost. 

Percussion  over  the  lower  part  of  the  chest  yields  flatness,  extend- 
ing upward  to  the  surface  of  the  fluid.  The  height  of  this  surface  is 
not  altered  by  deep  inspirations  or  forced  expirations,  but  its  relations 
are  changed  by  alterations  in  the  patient's  position,  unless  the  effusion 
entirely  fills  the  pleural  sac  or  there  are  complete  adhesions  above  its 
surface. 

Above  the  fluid  the  resonance  is  exaggerated,  and  in  exceptional 
cases  it  may  have  a  vesiculo-tympanitic  or  amphoric  quality. 


64 


PULMONARY  DISEASES. 


Investigations  by  Damoiseau,  of  Paris,  and  more  recently  by  the  late 
Dr.  Ellis,  of  Boston,  show  that  usually,  when  the  pleural  sac  is  no  more 
than  one-fourth  or  one-third  filled,  the  upper  surface  of  the  fluid  corre- 
sponds to  a  curved  line  known  as  the  letter  S  curve,  termed  by  Ellis 
the  curved  line  of  flatness  (Fig.  19). 

G.  M.  Garland,  in  his  monograph  on  Pneumo-dynamics,  describes 
this  curved  line  as  follows :  "  Its  lowest  point  is  found  behind,  near  the 
spinal  column.  From  this  point  it  curves  upward  and  outward  across 
the  lateral  region,  where  it  is  highest  ;  and  from  this  point  it  proceeds 
almost  horizontally  forward  to  the  sternum."  The  experiments  of 
Garland  demonstrate  that,  instead  of  a  gradual  rising  of  the  fluid  in 


c<o    **Vv 


Fig.  19.—  Curved  Line  of  Flatness  in  Pleurisy,  Posterior  View  (Garland).  C.  B,  Letter  S 
curve;  A,  B,  C,  triangle  of  dulness. 

the  lower  portion  of  the  chest,  carrying  the  lung  above  it,  and  main- 
taining a  horizontal  surface,  as  is  usually  supposed,  its  upper  line  nearly 
corresponds  to  the  natural  outline  of  the  base  of  the  lung.  This  is  sup- 
posed to  be  due  to  the  elasticity  of  the  lung,  which  holds  the  fluid  in 
this  unnatural  position.  I  refer  those  interested  in  this  matter  to  Gar- 
land's monograph  for  a  complete  exposition  of  the  subject. 

If  a  line  be  drawn  horizontally  backward  from  the  highest  point  of 
the  curved  line  of  flatness  in  the  lateral  region  to  the  spinal  column,  a 
somewhat  triangular  space  will  be  left  between  it  and  the  posterior  part 
of  the  curved  line  of  flatness.  This  space  is  termed  by  Garland  the 
triangle  of  dulness  (Fig.  10).  It  is  bounded  below  and  externally  by  the 
letter  S  curve,  internally  by  the  spinal  column,  and  above  by  a  line 
drawn  backward  from  the  highest  point  of  the  curved  line  in  the  lateral 
region.     This  superior  boundary  is  not  necessarily  horizontal,  but  it 


ACUTE  PLEURISY. 


65 


may  be  so  considered  for  the  sake  of  illustration.  In  this  triangular 
space  we  have  no  fluid,  but  the  resonance  is  less  than  above  it.  This 
dulness  is  due  to  partial  compression  of  the  lung  against  the  spinal 
column.  In  order  to  recognize  the  curved  line  throughout  its  entire 
extent,  we  must  not  compare  the  affected  with  the  sound  side  posteri- 
orly, as  it  is  not  the  distinction  between  resonance  and  flatness  which 
we  wish  to  obtain,  but  the  distinction  between  dulness  and  flatness. 
Percussion  should  be  made  in  perpendicular  lines  at  several  places, 
either  from  above  downward  or  from  below  upward.  By  this  method, 
we  easily  distinguish  between  the  dulness  over  the  compressed  lung  and 
the  flatness  over  the  fluid,  and  between  the  character  of  the  resonance 
in  these  positions  and  that  of  the  lung  above  them.  Failure  to  recog- 
nize the  true  character  of  the  percussion  note  in  these  different  localities 


7  y  ■ 


Fig.  20.— Curved  List:  of  Flatness  in  Pleurisy,  Anterior  View  (Ellis).     Letter  S  curve, 
anterior  view. 

has  caused  authors  to  describe  the  upper  surface  of  the  fluid  as  corre- 
sponding to  a  horizontal  line.  If  we  recollect  that  the  fluid  in  the 
pleural  sac  conforms  itself  more  or  less  perfectly  to  the  natural  contour 
of  the  base  of  the  lung,  we  shall  understand  why  the  line  does  not  undergo 
greater  changes  with  alteration  in  the  position  of  the  patient.  Suppose, 
for  instance,  that  we  find  the  level  of  the  fluid,  in  front,  at  the  fifth  rib, 
when  the  patient  is  in  the  erect  position;  upon  causing  him  to  lie  on  his 
back,  according  to  the  generally  accepted  opinion,  the  line  of  flatness 
should  still  remain  horizontal,  and  would  then  be  found  running  longi- 
tudinally along  the  lateral  region.  In  fact,  however,  this  never  occurs. 
On  the  contrary,  the  line  of  flatness  is  not  likely  to  be  dej)ressed  in  front 
more  than  one  or  two  inches  by  this  change  in  the  patient's  position, 
and  it  will  be  found  running  more  or  less  obliquely  downward  and 
backward,  instead  of  longitudinally. 

When  the  pleural  cavity  is  nearly  filled  with  fluid,  we  frequently  get 
tympanitic  resonance  over  its  apex,  especially  if  the  patient  is  recum- 
5 


6  G  PTJLMONAR  Y  DIS  EA  SES. 

bent.  In  attempting  to  explain  this  phenomenon,  we  are  once  more 
confronted  with  the  opposing  statements  that  tympanitic  resonance  is 
low  pitched  and  that  it  is  high  pitched.  Fraentzel — who  believes  the 
tympanitic  resonance  to  be  low  in  pitch — in  giving  the  reasons  for  this 
sign,  quotes  from  Wintrich  and  Traube,  who  claim  that  the  pitch  in 
pulmonary  percussion  is  dependent  upon  two  elements  :  first,  the  volume 
of  air  beneath  the  point  percussed;  second,  the  tension  of  the  lung  tis- 
sue; claiming  also  that  the  pitch  of  the  percussion  sound  is  directly 
proportionate  to  the  tension  and  inversely  proportionate  to  the  volume 
of  the  oscillating  column  of  air.  In  other  words,  as  the  lung  is  dimin- 
ished in  volume  the  pitch  is  raised;  or  as  it  again  approaches  the  nor- 
mal size,  the  pitch  is  lowered  according  to  the  amount  of  air  which  it 
contains;  and  as  the  tension  of  the  lung  is  increased  the  pitch  is  elevated. 
Therefore  if  the  diminution  in  volume  which  raises  the  pitch  and  the 
diminution  in  tension  which  lowers  the  pitch  be  equally  balanced,  the 
pitch  will  remain  unaltered.  It  therefore  follows  that  in  moderately 
large  pleuritic  effusions  which  yield  tympanitic  resonance  in  the  infra- 
clavicular region,  the  diminution  in  tension  [low  pitch)  must  exceed  the 
diminution  in  volume  {high pitch).  Flint,  and  Da  Costa  (Medical  Diag- 
nosis, 1890,  p.  265),  who  consider  tympanitic  resonance  to  be  of  high 
pitch,  believe  that  this  sign  in  pleurisy  is  due  in  great  part  to  the  conducted 
resonance  from  the  trachea  and  the  bronchial  tubes.  Both  of  these 
reasons  may  be  in  part  correct,  but,  as  I  pointed  out  in  a  communication 
to  the  Chicago  Medical  Journal  and  Examiner,  March,  1877,  it  is  more 
than  probable  that  this  sign  results  mainly  from  a  collection  of  watery 
vapor  above  the  fluid  in  the  pleural  sac.  Vaporization  of  water  occurs  even 
at  a  low  temperature,  but  at  a  temperature  of  one  hundred  and  one  or 
two  degrees  Fahrenheit,  under  ordinary  pressure,  it  takes  place  rapidly. 
This  process  must  therefore  be  going  on  constantly  when  fluid  collects 
in  the  pleural  cavities,  and  as  soon  as  the  serous  surfaces  become  so 
altered  by  inflammation  that  they  are  incapable  of  absorbing  the  vapor 
as  rapidly  as  it  is  formed,  it  will  collect  above  the  fluid  until  the  tension 
becomes  sufficient  to  prevent  its  further  formation.  A  cavity  so  formed, 
filled  with  watery  vapor,  must  yield  tympanitic  resonance.  I  am  con- 
vinced of  the  correctness  of  this  theory  by  experiments  not  only  with 
fluids  outside  of  the  body,  but  also  on  patients  with  the  pleural  cavity 
almost  filled  with  fluid,  and  in  whom  when  recumbent  tympanitic  res- 
onance was  plainly  discernible,  just  beneath  the  clavicle,  while  on  in- 
version of  the  patient  so  that  the  base  of  the  chest  was  the  highest, 
tympanitic  resonance  would  be  found  over  a  small  area  at  the  base  of 
the  pleural  sac. 

Biegauski  (Schmidt's  Jahrbuch,  August,  1889)  calls  attention  to  a  new  sign  of 
right-sided  pleurisy  ;  increased  cardiac  dulness  laterally  appears  with  effusion 
even  in  small  amount,  caused,  he  thinks,  by  atelectasis  of  the  middle  lobe  of  the 


ACUTE  PLEURISY.  67 

lung,  so  exposing  more  of  the  heart.     This  increased  dulness  is  said  to  remain 
for  a  year  or  more  after  absorption  of  the  effusion. 

By  auscultation  the  respiratory  murmur  above  the  level  of  the  fluid 
is  often  found  slightly  exaggerated.  The  vesicular  murmur  cannot  be 
heard  over  the  fluid  excepting  in  a  small  zone  near  its  upper  level,  where 
the  sounds  are  feebly  transmitted  from  the  lungs.  Over  the  fluid,  vocal 
resonance  is  either  lost  or  the  voice-sounds  are  indistinct  and  distant. 
Sometimes  consolidation  of  the  lower  part  of  the  lung  causes  aegophony 
near  the  upper  surface  of  the  fluid.  Often  a  few  friction  sounds  may 
be  heard  in  the  same  position,  but  none  over  the  rest  of  the  fluid. 

During  the  third  stage  of  pleurisy  the  signs  denote  gradual  return  to 
a  healthy  condition.  Distention  becomes  less,  respiratory  movements 
are  freer,  and  the  vocal  fremitus  gradually  appears  first  at  the  upper 
portion  of  the  chest.  The  upper  limit  of  the  liquid,  as  ascertained  by 
percussion,  slowly  falls  until  the  fluid  is  entirely  absorbed.  Sometimes, 
over  the  lower  part  of  the  chest,  more  or  less  dulness  persists  for  a  long 
time,  or  the  resonance  may  not  again  become  normal,  owing  to  the  re- 
maining inflammatory  lymph  or  to  thickening  of  the  pleura,  which 
may  permanently  separate  the  lung  a  short  distance  from  the  chest  wall. 

The  respiratory  sounds  gradually  return,  at  first  feeble  and  distant, 
but  growing  more  distinct,  until  they  finally  become  normal.  Occa- 
sionally the  respiratory  sounds  remain  harsh  and  tubular  in  quality,  on 
account  of  the  imperfect  expansion  of  the  air  vesicles,  and  bronchial 
breathing  may  remain  near  the  vertebral  column  for  some  time.  Usu- 
ally, as  the  two  surfaces  of  the  pleura  again  come  into  contact,  friction 
sounds  are  obtained,  which  may  continue  for  a  short  time  only  or  for 
several  months. 

The  heart  and  the  abdominal  organs  gradually  return  to  their  nor- 
mal positions,  as  shown  by  percussion  and  auscultation. 

In  some  rare  cases,  however,  when  the  heart  is  crowded  to  the  right  of  the 
sternum  by  an  effusion  into  the  left  pleural  sac,  adhesions  take  place  which  per- 
manently retain  the  organ  in  its  abnormal  situation.  Sometimes  the  absorption 
of  a  large  and  long-continued  effusion  in  the  right  sac  is  followed  by  a  permanent 
dislocation  of  the  heart  to  the  right  of  the  sternum,  due  to  the  tendency  of  the 
surrounding  parts  to  fill  the  space  which  should  be  occupied  by  the  unexpanded 
lung. 

If  the  air  vesicles  cannot  fully  expand,  owing  to  the  partial  disorgan- 
ization of  lung  tissue  from  long-continued  compression  or  because  the 
lung  has  been  bound  down  by  inflammatory  adhesions,  the  chest  may 
not  again  attain  its  normal  condition.  There  will  be  consequent  loss  of 
motion  and  retraction  of  the  affected  side,  with  more  or  less  dulness 
upon  percussion  and  feeble  or  suppressed  respiration.  In  the  most  pro- 
tracted cases  the  upper  portion  of  the  lung  becomes  only  partially  ex- 
panded, and  in  this  region  there  will  be  dulness  upon  percussion,  with 


68  PULMONARY  DISEASES. 

deficient  vesicular  murmur  and  broncho-vesicular  respiratory  sounds, 
together  with  exaggerated  vocal  resonance. 

Diagnosis. — The  essential  points  in  the  diagnosis  of  acute  pleurisy 
are :  the  indistinct  chills,  the  sharp  pain  in  the  side,  friction  fremitus 
and  murmurs;  flatness  on  percussion  with  change  in  the  level  of  fluid 
by  changes  in  the  patient's  position,  with  absence  of  vocal  fremitus  and 
absence  or  great  diminution  in  the  intensity  of  all  respiratory  and 
vocal  signs  over  fluid  effusions. 

The  differential  diagnosis  of  pleurisy  is  usually  easy,  yet  various  dis- 
eases have  been  mistaken  for  it.  The  affections  liable  to  cause  error  in 
diagnosis  are  pleurodynia,  intercostal  neuralgia,  pericarditis,  pneumonia, 
phthisis,  collapse  of  the  lung  due  to  pressure  on  a  main  bronchus,  can- 
cer of  the  lung,  aneurism  of  the  aorta,  and  enlargement  of  the  liver  or 
spleen. 

Pleurisy  is  only  likely  to  be  mistaken  for  pleurodynia  or  intercostal 
neuralgia  in  the  first  stage  of  the  acute  variety,  when  the  pain  and  con- 
sequent impairment  of  the  respiratory  movements  and  murmur  are  the 
same  as  in  the  latter  affections.  The  distinction  may  be  made  by  re- 
membering that  the  pain  of  pleurodynia  is  apt  to  be  fugitive,  shifting, 
and  often  bilateral,  and  is  likely  to  be  increased  by  slight  pressure  and 
by  muscular  contractions.  The  pain  in  intercostal  neuralgia  is  confined 
to  one,  two,  or  three  tender  points  along  the  course  of  the  intercostal 
nerves;  the  neuralgic  diathesis  is  commonly  to  be  found  in  this  affection 
and  frequently  coincident  uterine  disease.  On  the  other  hand,  the  pain 
in  pleurisy  is  deep-seated,  and  although  there  is  tenderness  on  pressure, 
it  is  not  confined  to  isolated  points  along  a  nerve;  and  by  auscultation 
we  detect  a  friction  sound  which  is  not  obtained  in  pleurodynia  or  in 
intercostal  neuralgia.    In  these  latter  there  is  usually  no  fever. 

The  diagnosis  between  pericarditis  and  pleurisy  affecting  the  left  side 
is  based  upon  the  locality  of  the  pain  and  the  friction  sounds,  and  the 
relation  of  the  latter  to  the  respiratory  movements. 

The  pain  of  pericarditis  is  located  in  the  precordial  region ;  that  of 
pleurisy  more  laterally.  The  friction  sound  in  pericarditis  is  heard 
most  distinctly  at  the  left  border  of  the  sternum  near  the  fourth  costal 
cartilage;  that  of  pleurisy  usually  farther  to  the  left  and  lower  down. 
The  friction  sound  in  pericarditis  is  independent  of  the  respiratory 
movements,  and  does  not  cease  when  the  patient  holds  his  breath.  In 
pleurisy  these  sounds  are  not  heard  except  during  respiration. 

Exceptional. — The  action  of  the  heart  may  cause  a  friction  sound  between 
the  anterior  portions  of  the  left  pleura  which  will  not  disappear  when  respiration 
ceases,  but  this  is  extremely  uncommon. 

The  diagnostic  points  of  pleurisy  as  distinguished  from  pneumonia 
are  as  follows : 


ACUTE  PLEURISY.  69 

Symptoms. 

Pleurisy.  Pneumonia. 

Chill  absent  or  slight.  Onset  with  marked  chill. 

Temperature  low,  rarely  above  102°  F.  Fever  high,  102c-105"  F. 

Slight  prostration.  Marked  prostration. 

Cough  hacking,  dry.  Cough  followed  by  tenacious,  often 

bloody  or  rusty  sputum. 
Respiration  jerking.  Respiration  panting. 

Stitch-like    pain,    usually    below  the  Pain  usually  duller  and  less  intense. 

nipple. 
Aspiration  gives   additional   evidence 

of  effusion. 

Inspection. 
Countenance   notably  pale    and   anx-  Countenance  apt  to  be  flushed. 

ious  at  the  onset. 
Decubitus  often  on  the  affected  side. 

Palpation. 
Vocal  fremitus  diminished  or  absent.  Vocal  fremitus  increased. 

Percussion. 
Flatness  and  sense  of  resistance  over  Dulness  rather  than  flatness. 

the  fluid. 
Displacement  of  adjacent  oi'gans.  No  displacement. 

Auscultation. 
Vocal  sounds  feeble.  Vocal  sounds  exaggerated. 

Inspiratory    and    expiratory    friction  Crepitant  rales  and  later  numerous 

sounds  prior  to  effusion.  moist  rales. 

Respiratory  sounds    feeble  or  absent  Vesicular  murmur  feeble  or  absent, 

over  effusion.  but  bronchial  breathing  distinct  in 

second  stage. 

The  most  distinctive  sign  of  pleuritic  effusion  is  absence  of  vocal 
fremitus  over  the  affected  part,  instead  of  increased  fremitus  as  in  pneu- 
monia. 

Pleurisy  is  distinguished  from  phthisis  by  the  history  and  by  the 
same  signs  which  differentiate  it  from  pneumonia,  also  by  the  fact  that 
phthisis,  affecting  the  greater  part  of  the  lower  lobe  of  one  lung,  will 
usually  affect  the  apex  of  the  opposite  lung,  whereas  the  signs  of  pleurisy 
are  usually  confined  to  the  lower  part  of  one  side.  In  phthisis  the  signs 
usually  progress  downward;  in  pleurisy,  upward. 

Many  signs  similar  to  those  of  pleurisy  with  extensive  effusion  ma]? 
appear  in  collapse  of  a  lung  from  compression  of  its  main  bronchus,  viz., 
loss  of  motion  of  the  side,  absence  of  vocal  fremitus,  dulness  or  flatness 
on  percussion,  and  absence  of  respiratory  and  vocal  signs.  When  these 
signs  exist,  the  diagnosis  must  be  based  mainly  on  the  position  of  the 
heart.  Moderate  pleuritic  effusions,  where  no  adhesion  of  the  pleural 
surfaces  has  taken  place,  would  be  easily  differentiated  from  the  condi- 
tion under  consideration  by  changes  in  the  level  of  the  fluid.  But 
where  the  effusion   is  circumscribed,  or  when   it    completely  fills  the 


70  PULMONARY  DISEASES. 

pleural  cavity,  this  sign  would  not  be  present.  In  pleurisy  with  consid- 
erable effusion,  the  heart  is  more  or  less  displaced  toward  the  opposite 
side.     This  does  not  occur  in  collapse  of  the  lung. 

The  essential  difference  in  the  signs  of  these  two  conditions  may  be 
seen  at  a  glance  in  the  following  table : 

Pleurisy.  Collapse  of  lung  from  compression 

of  the  main  bronchus. 

Heart  usually  more  or  less  displaced  Heart  not  displaced. 

to  opposite  side. 

Side  often  distended.     Side  not  re-  Side  not  distended,  may  be  retracted, 

tracted  excepting  in  protracted  cases.  and  would  always  be  retracted  except 

that  collapse  of  the  air  vesicles  causes 
diminished  pressure  on  the  organ.  This 
favors  dilatation  of  the  blood-vessels, 
and  sometimes  causes  congestion  with 
exudation  which  fills  the  air  vesicles 
and  distends  the  lung  to  its  normal  size. 

Dulness  usually  begins  near  the  middle  of  the  lung  in  pulmonary 
cancer,  and  progresses  irregularly  in  different  directions,  leaving  here 
and  there  patches  of  normal  resonance  surrounded  by  flatness.  In  pleu- 
risy flatness  begins  at  the  base  of  the  chest  and  is  uniform.  The  consti- 
tutional symptoms  of  the  two  diseases  are  usually  different. 

The  occurrence  of  empyema  with  perforation  of  the  chest  walls,  in  the  course 
of  the  aorta,  might  cause  a  pulsating  tumor  which  would  closely  simulate 
aneurism  of  the  aorta.  It  would  be  distinguished  from  the  latter  disease  by  the 
presence  of  signs  of  empyema  in  the  lower  part  of  the  chest. 

Pleurisy  of  the  left  side  is  distinguished  from  enlargement  of  the 
spleen  by  the  following  points.  An  enlarged  spleen  seldom  encroaches 
much  upon  the  thorax,  and  therefore  causes  little  or  no  distention  of  the 
side,  and  no  bulging  of  the  intercostal  spaces  or  displacement  of  the 
heart.  Upon  percussion,  dulness  is  found  to  extend  in  front  higher 
than  behind,  and  the  level  of  its  upper  surface  does  not  materially 
change  with  changes  in  the  patient's  position.  There  is  also  a  large  area 
of  flatness  below  the  diaphragm. 

Even  skilful  diagnosticians  have  frequently  mistaken  enlargement  of 
the  liver  for  pleuritic  effusions.  The  differential  signs  will  be  seen  in 
the  following  table : 

Pleuritic  effusions.  Hypertrophy  of  the  liver. 

Inspection. 
Frequently,  bulging  of  the  intercos-  There  may  be  bulging  of  the  chest, 

tal  spaces.  but  the  intercostal  spaces  are  not  espe- 

cially prominent. 

Palpation. 
Occasionally,  fluctuation.  No  fluctuation. 


ACUTE  PLEURISY.  71 

Pleuritic  effusions.  Hypertrophy  of  the  liter. 

Percussion . 
Dulness    extending    higher    behind  Dulness  extending   in   front  higher 

than  in  front.  than  behind,  because  the  shelving  bor- 

der of  the  lung  posteriorly  intervenes 
between  the    liver    and  the    thoracic 
walls. 
The  line  of  absolute  flatness  usually  The  line  of  flatness  is  not  materially 

varies  with  changes  in  the  position  of  affected  by  changes  in  the  patient's 
the  patient,  and  is  not  depressed  or  ele-  position,  but  is' depressed  and  elevated 
vated  during  inspiration  or  expiration.         by  inspiration  and  expiration. 

Auscultation. 

The  respiratory  murmur  is  heard  in  The  respiratory  murmur  is  heard  be- 

tront,  at  a  lower  level  than  behind,  and        hind   at  a  lower   level  than  in  front, 

this  level  is  not  materially  affected  by        and  this  level  is  depressed  during'  deep 

deep  inspiration.  inspiration  and  elevated  in  expiration. 

Pkogxosis  of  acute  and  subacute  pleurisy.  In  ordinary  cases  of 
acute  pleurisy  recovery  usually  occurs  within  two  or  three  weeks,  hut 
they  may  lapse  into  the  subacute  and  chronic  forms.  A  permanent 
lesion  usually  remains  in  some  part  of  the  pleural  sac  after  sero-fibrinous 
pleurisy  (Loomis),  frequently  in  the  form  of  thickening  and  adhesions; 
these  predispose  to  repeated  attacks,  resulting  in  greater  pleural  thick- 
ening, connective-tissue  hyperplasia  and  contraction,  thus  limiting  the 
function  of  the  lung  and  favoring  attacks  of  bronchitis  and  the  inroads 
of  phthisis. 

Diaphragmatic  pleurisy  in  the  dry  form  is  common  and  generally 
results  in  adhesions,  which  may  fix  the  diaphragm  as  high  in  some  cases 
as  the  fourth  rib,  usually  at  the  seventh  or  eighth,  thus  greatly  dimin- 
ishing the  vertical  diameter  of  the  chest  cavity,  rendering  subsequent 
thoracentesis,  if  necessary,  dangerous,  and  favoring  rupture  of  the  dia- 
phragm in  the  sudden  strain  of  severe  bodily  exertion. 

Subacute  pleurisy  may  be  protracted  for  months,  resulting  in  per- 
manent crippling  of  the  lung  from  compression,  and  it  may  be  in 
emphysema  of  the  opposite  organ ;  or  the  fluid  may  become  purulent, 
especially  in  children.  Pleurisy  complicating  grave  disorders  such  as 
pyaemia,  septicaemia,  or  Bright's  disease  is  obviously  unfavorable.  In  the 
latter  affection  and  in  very  acute  pleurisy,  effusion  may  be  so  rapid  and 
copious  as  to  cause  death  in  a  day  or  two. 

Extreme  compression  of  the  lung  in  any  case  invites  sudden  conges- 
tion or  oedema  of  its  fellow,  and  consequent  death. 

Danger  of  sudden  death  from  compression  of  the  heart,  according  to 
Leichtenstern  {Deutsche?  Archiv  fur  klinische  Medicin,  Band  IV),  is 
greater  if  a  large  effusion  occurs  on  the  right  side,  probably  owing  to  the 
greater  weakness  of  the  walls  of  the  right  ventricle.  However,  in  chil- 
dren a  large  effusion  on  the  left  threatens  sudden  fatal  syncope  from  its 
effect  in  twisting  the  great  vessels. 


72  PULMONARY  DISEASES. 

Treatment. — The  patient  should  be  kept  quiet  in  bed,  and  put  upon 
an  nnstimulating  diet  unless  great  weakness  demand  the  opposite. 
Talking  should  be  prohibited,  and  all  voluntary  motion  avoided.  The 
respiratory  movements  may  be  restricted  by  strapping  the  side  with 
strips  of  adhesive  plaster  running  diagonally,  from  above  downward 
and  forward  and  downward  and  backward,  and  also  horizontally;  a 
broad  strip  of  rubber  plaster  applied  during  expiration,  or  a  wide  elastic 
bandage,  may  be  employed  for  the  same  purpose.  When  these  are  not 
used,  hot  poultices  may  be  beneficially  employed. 

Opiates  or  some  of  the  more  recent  analgesics,  such  as  antipyrine, 
acetanilide,  or  phenacetin,  which  are  to  be  preferred  when  there  is 
much  fever  and  in  most  cases  where  the  pain  is  not  extreme,  should  be 
given  in  sufficient  quantity  to  relieve  pain.  Loomis  recommends  the 
application  of  a  constant  galvanic  current  to  the  affected  side  for  the 
relief  of  pain,  which  continues  after  the  subsidence  of  friction  sounds. 
Sometimes  the  pleural  sac  rapidly  fills  with  serum,  and  the  question 
of  aspiration  will  be  suggested.  With  regard  to  this,  the  following 
rule  is  important :  Do  not  aspirate  in  acute  pleurisy  until  about  the  mid- 
dle of  the  second  week  or  until  all  acute  symptoms  have  passed,  unless 
compelled  to  do  so  to  relieve  great  dyspnoea.  In  the  third  stage  of  the 
disease,  tonics  and  potassium  iodide,  with  counter-irritation  by  blisters 
or  iodine,  are  indicated.  Absorption  of  the  fluid  may  also  be  favored, 
by  free  sweating  brought  about  by  the  use  of  jaborandi,  pilocarpine,  or 
the  hot-air  bath,  and  by  such  diuretics  as  squills,  comp.  spts.  of  juniper, 
and  potassium  bitartrate,  acetate,  or  iodide.  Sodium  salicylate,  or  salol 
in  large  doses,  is  recommended  as  sometimes  producing  prompt  sub- 
sidence of  serous  pleurisy  where  other  remedies  prove  unsatisfactory  (J. 
Drzewiecki,  Medical  Record,  July,  1869). 

SUBACUTE    PLEURISY. 

Subacute  pleurisy,  also  called  chronic  pleurisy  by  some  authors,  con- 
sists of  a  low  grade  of  inflammation  of  the  pleura,  most  frequently  char- 
acterized by  mildness  of  the  symptoms,  absence  of  pain,  and  slight  con- 
stitutional disturbance  with  the  effusion  of  an  excessive  amount  of  serum 
often  completely  filling  the  pleural  cavity. 

Anatomical  axd  Pathological  Characteristics. — These  hav- 
ing been  already  described  under  the  general  title  Pleurisy,  it  only  re- 
mains to  be  said  that  this  is  pre-eminently  the  "pleurisy  with 
effusion."  The  morbid  processes  occurring  in  the  pleura  are  less  rapid 
than  in  the  acute  variety;  the  pleural  thickening  and  formation  of 
fibrous  tissue  is  more  extensive;  the  effused  liquid  larger  in  quantity; 
the  results  of  pressure  more  grave. 

Etiology. — The  causes  are  similar  to  those  of  the  acute  form,  but 
malnutrition  and  tuberculosis  are  the  most  frequent. 


SUBACUTE  PLEURISY. 


Td 


Symptomatology. — The  principal  symptoms  are  dyspnoea,  loss  of  ap* 
petite,  emaciation,  vomiting,  and  more  or  less  cough. 

Fever  of  from  one  to  two  degrees  is  common.  Pain  may  be  slight 
or  altogether  absent. 

It  is  surprising  how  great  the  effusion  may  become  in  this  affection 
before  the  difficulty  in  breathing  becomes  noticeable. 

The  signs  are  those  of  the  second  and  third  stages  of  acute  pleurisj 
with  extensive  effusion  (Fig.  21). 


Bronchial  breathing. 


Flatness;   absence  of  respi- 1 
ratory  and  vocal  sounds,     i  " 


Fig.  21.— Subacute  Pleurisy. 


Diagnosis  and  Prognosis. — The  subject  of  diagnosis  and  progno- 
sis of  subacute  pleurisy  has  been  included  in  that  of  acute  pleurisy. 

Treatment. — The  indications  are  for  improved  nutrition  and  removal 
of  the  effusion. 

Very  moderate  catharsis,  diuresis,  and  diaphoresis,  if  employed  short 
of  exhausting  depletion,  especially  in  the  more  robust,  are  advisable,  not 
so  much  to  influence  absorption  of  the  pleuritic  effusion  as  to  favor  im- 
provement of  the  general  nutritive  processes.  Mild  counter- irritation  is 
also  useful.  The  diet  should  be  nutritious,  easily  digested,  and  moder- 
ately stimulating,  composed  of  animal  and  farinaceous  broths,  beef  prep- 
arations, eggs,  and  in  some  cases  such  spirits  as  sherry  and  port.  These, 
and  bitter  tonics,  as  the  various  preparations  of  hydrastis,  calisaya, 
columbo,  and  gentian,  combined  with  ferruginous  remedies,  and  the 
employment  of  mercury  and  potassium  iodide  in  alterative  doses,  best 
meet  the  first  requirement. 

If  in  a  couple  of  weeks  the  fluid  has  not  materially  diminished,  it 
should  be  withdrawn  by  an  aspirator,  providing  there  is  sufficient  to 
more  than  half  fill  the  pleural  cavity,  or  even  when  the  collection  is 
small  if  it  causes  dyspnoea  or  discomfort  in  the  side.  Whenever  the 
cavity  is  completely  filled  and  the  heart  displaced,  even  though  no  urgent 


74  PULMONARY  DISEASES. 

symptoms  occur,  no  time  should  be  lost  in  performing  the  operation. 
In  cases  of  bilateral  effusion,  especially  where  there  is  cyanosis  or  great 
dyspnoea;  when  emaciation  occurs  with  indigestion  and  feeble  circula- 
tion; when  pleural  effusion  complicates  pericarditis,  heart  disease,  pneu- 
monia, severe  bronchitis,  or  Blight's  disease;  or  when  the  fluid  becomes 
purulent — operative  procedure  must  not  be  delayed.  In  operating,  it  in- 
most convenient  to  have  the  patient  sitting  astride  of  a  chair  with  the 
arms  folded  and  resting  upon  the  back  of  the  chair,  and  the  body  in- 
clined slightly  forward :  but  if  the  patient  is  too  weak  to  sit  up,  he  may 
remain  iu  the  recumbent  posture,  lying  close  to  the  edge  of  the  bed. 
General  anaesthetics  are  seldom  used ;  the  parts  may  be  thoroughly  be- 
numbed by  injecting  deep  into  the  intercostal  space,  and  just  beneath 
the  skin,  with  a  fine  needle,  a  few  drops  of  a  two  per  cent  solution  of 
cocaine,  or  of  the  solution  recommended  for  local  anaesthesia  (Form. 
140).  It  is  well  to  tell  the  patient  that  he  need  have  no  fear  until  told 
the  plunge  is  to  be  made,  in  order  to  save  him  much  anxiety  and  enable 
the  physician  to  make  his  examination  more  deliberately.  The  surface 
to  be  punctured  should  be  surgically  clean  and  the  instruments  aseptic. 
I  find  it  convenient  to  dip  the  thoroughly  cleansed  needle  into  a  mix- 
ture of  equal  part.-  of  carbolic  acid  and  olive  oil.  Any  of  the  aspirators 
in  common  use  may  be  employed,  but  the  simpler  are  usually  the  best. 
It  is  generally  best  to  use  a  medium-sized  needle,  and  the  cocks  should 
be  closed  and  the  air  nearly  exhausted  from  the  aspirator  before  it  is 
introduced.  The  puncture  is  best  made  near  the  angle  of  the  ribs  in 
the  sixth,  seventh,  or  eighth  interspace.  It  is  my  custom  to  make  it 
high.  When  the  pleural  sac  is  only  partially  filled  with  fluid,  we  ascer- 
tain the  upper  surface  of  this,  and  make  the  puncture  about  an  inch 
below  it.  If  the  operation  is  at  the  lower  part  of  the  chest,  the  needle 
is  apt  to  strike  the  diaphragm,  or,  if  this  does  not  occur,  as  soon  as  a  part 
of  the  liquid  has  been  withdrawn,  the  diaphragm  is  forced  upward 
against  the  needle,  causing  pain  and  preventing  further  withdrawal  of 
fluid. 

The  skin  should  be  drawn  upward  about  half  an  inch  by  the  ends  of 
two  fingers,  which  are  then  pressed  firmly  iuto  the  intercostal  space; 
between  them  the  needle  is  thrust  inward  and  upward  in  the  direc- 
tion corresponding  to  the  slant  of  the  adjacent  costal  surfaces,  to  avoid 
the  danger  of  striking  a  rib.  When  all  is  ready  the  patient  should  be 
forewarned  of  the  sudden  coming  pain,  and  the  needle  plunged  in  until 
it  enters  the  pleural  cavity.  The  air  cock  is  then  opened  and  the  fluid 
slowly  withdrawn.  During  this  procedure,  if  cough,  pain,  or  dyspnoea 
or  a  feeling  of  constriction  of  the  chest  or  weight  upon  the  sternum 
occur,  the  aspiration  should  be  discontinued  at  once,  whether  the  fluid 
has  all  been  withdrawn  or  not.  The  amount  of  fluid  removed  at  one 
time  is  exceedingly  variable,  being  from  a  few  ounces  to  several  pints, 
and  not  infrequently  rapid  absorption  has  been  known  to  follow  removal 


SUBACUTE  PLEURISY.  75 

of  even  a  few  drachms.  The  operation  should  be  repeated  within  from 
five  to  ten  days  if  the  fluid  reaccumulates.  Usually  after  these  measures 
the  patient  immediately  improves,  the  appetite  is  better,  weight  in- 
creases, and  the  fever  may  entirely  disappear.  Subsequent  treatment  of 
the  case  should  be  of  a  tonic  nature,  and  should  include  systematic  and 
careful  exercise  of  the  muscles  of  the  trunk,  and  breathing  exercises. 
Eecovery  is  sometimes  greatly  aided  by  a  sea  voyage  or  change  of  climate, 
especially  to  a  high  altitude  when  mountain-climbing  will  develop  the 
respiratory  muscles  and  the  air  cells  will  be  expanded.  The  patient 
should  be  told  that  he  must  expect  pain  in  the  affected  region  on  pul- 
monary and  general  muscular  exercise,  for  some  weeks  or  months. 


CHAPTER  VI. 
PULMONARY    DISEASES.— Continued, 

CHRONIC    PLEUKISY    OK    EMPYEMA. 

The  term  empyema  is  applied  to  pleurisy  when  the  inflammation  is 
protracted  and  pus  instead  of  serum  occupies  the  pleural  sac. 

Anatomical  and  Pathological  Characteristics. — If  sero-fibri- 
nous  pleurisy  become  suppurative,  the  plastic  elements  undergo  degener- 
ative changes  by  the  action  of  various  micro-organisms,  and  are  found 
to  consist  of  pus  cells  and  shreds  and  flakes  of  semi-purulent  coagula 
immersed  in  serum.  If  the  empyema  be  primary,  leucocytes,  round  cells, 
and  endothelial  cells,  more  or  less  degenerate,  appear  on  the  pleural  sur- 
face, to  be  washed  by  the  serum  to  the  bottom  of  the  pleural  sac.  The 
lymphatics,  cells,  and  pericellular  spaces — in  the  serous  and  subserous 
tissues — contain  active  micro-organisms  in  greater  or  less  number.  The 
effects  of  pressure  upon  the  heart  and  lungs  in  empyema  do  not  differ 
from  those  which  occur  in  pleurisy  with  serous  effusion. 

Etiology. — Empyema,  according  to  Bouveret,  is  most  prevalent  dur- 
ing the  first  five  years  of  life,  and  pleuritic  effusions  are  more  apt  to  be- 
come purulent  in  children  than  in  adults.  Whether  idiopathic  or  not,  it 
usually  occurs  in  those  of  hereditary  weakness  or  those  who  are  debili- 
tated by  disease  or  irregular  habits. 

It  may  follow  trauma  or  opening  into  the  pleural  sac  of  an  abscess 
in  the  liver,  lung,  or  thoracic  wall.  Pneumonia  and  typhoid  fever  are 
frequent  causes,  or  it  may  complicate  rheumatism,  or  scarlet  fever  and 
some  other  contagious  diseases,  or  pyasmia  or  septicaemia.  More  recently 
influenza  has  been  assigned  as  an  occasional  cause. 

Symptomatology. — The  symptoms  of  empyema  denote  serious  con- 
stitutional disturbance.  The  most  important  are :  rapid  pulse,  dyspnoea, 
cough  and  pain,  high  temperature,  dry  brown  tongue,  hectic  and  night 
sweats,  with  loss  of  appetite,  vomiting,  and  rapid  emaciation. 

The  signs  of  this  disease  are  much  the  same  as  those  of  subacute 
pleurisy,  but  usually  the  displacement  of  the  heart  and  of  other  adjacent 
organs  is  greater  in  proportion  to  the  amount  of  fluid.  Contraction  of 
the  chest  occurs  when  compression  of  the  lung  has  so  impaired  its  elas- 
ticity that  it  cannot  regain  its  original  volume  after  partial  absorption 
of  the  fluid.  The  chest  is  then  flattened  on  the  affected  side,  the  nipple 
depressed  and  nearer  the  median  line. 


CHRONIC  PLEURISY.  77 

occasionally  accompanying  curvature  of  the  spine  may  exist,  with  con- 
vexity toward  the  sound  side.  This  phenomenon  results  because  the  dorsal 
muscles  of  the  sound  side  are  no  longer  counterbalanced  by  those  of  the  affected 
oide,  wnich  become  paralyzed  by  the  persistent  pressure. 

Ordinarily  the  level  of  the  fluid  does  not  vary  with  changes  in  the 
position  of  the  patient,  owing  to  the  agglutination  of  the  pleural  sur- 
faces immediately  above  the  effusion.  In  this,  as  in  other  varieties  of 
pleurisy,  fluctuation  is  occasionally  detected  by  palpation.  Sometimes, 
with  large  effusions,  especially  in  the  left  pleura,  pulsation  of  the  side  is 
observed  synchronously  with  the  contraction  of  the  heart.  This  condi- 
tion is  called  pulsating  empyema.  If  the  pus  breaks  through  the  chest 
wall  and  appears  beneath  the  integuments,  the  tumor  thus  formed  gen- 
erally pulsates  strongly,  and  it  might  easily  be  mistaken  for  an  aneurisfn 
if  located  in  the  course  of  the  aorta  instead  of  being  at  the  lower  part  of 
the  chest.  Tumors  of  this  kind  often  enlarge  with  inspiration  and 
diminish  in  size  with  expiration. 

Exceptional. — Rarety,  empyema,  instead  of  occupying  its  usual  position  at  the 
base  of  the  chest,  may  be  confined  to  the  upper  part  of  the  pleural  sac,  or  to  a 
small  space  about  the  root  of  the  lung,  or  it  may  occupy  two  different  and  widely 
separated  localities. 

It  is  generally  considered  impossible  to  differentiate  between  serum  and  pus 
in  ihe  pleural  sac ;  but  Guido  Bocelli,  of  Rome,  claims  that  the  distinction  can 
be  made  by  attention  to  the  whispering-  vocal  resonance.  The  whisper  resonance, 
he  claims,  maj7  be  heard  at  the  base  of  serous  pleuritic  effusions,  but  will  not  be 
conducted  through  pus.  In  making-  this  distinction,  twro  conditions  must  be 
secured:  First,  immediate  auscultation  must  be  practised,  the  ear  being  pressed 
firmly  against  the  naked  chest,  and  all  external  sounds  excluded  by  closing  the 
other  ear  ;  second,  the  patient  must  be  so  placed  that  the  vibrations  produced  by 
whispering  shall  proceed  from  his  mouth  in  a  direction  diametrically  opposed  to 
the  listening  ear. 

Diagnosis. — Empyema  may  be  suspected  from  the  physical  signs  de- 
noting pleural  effusion,  together  with  the  symptoms  significant  of  puru- 
lent inflammation,  but  the  diagnosis  can  be  made  positive  only  by  explora- 
tory puncture. 

Prognosis. — This  is  generally  considered  unfavorable.  Chances  of 
recovery  lie  in  spontaneous  opening  and  discharge  of  the  pus,  a  very 
teoious  process,  or  in  its  removal  by  operative  procedure.  Without  such 
relief,  the  dangers  are :  death  from  sepsis,  pyasmia,  exhaustion,  or  from  the 
effects  of  pressure  upon  the  thoracic  organs.  In  acute  empyema,  death 
may  result  within  one  or  two  weeks,  but  in  the  more  chronic  forms  the 
patitmt  may  live  for  months,  or  even  three  or  four  years,  or  possibly 
longer.  Children  recover  much  more  satisfactorily  after  operation  than 
adults,  but  succumb  more  quickly  without  it.  Leichtenstern  considers 
the  escape  of  pus  in  the  empyema  of  children  as  an  almost  infallible 
indication  of  recovery.  He  believes  that  the  cases  of  so-called  sponta- 
neous cure  in  children  can  be  explained  by  the  theory  that  the  pleural 


78  PULMONARY  DISEASES. 

accumulation  in  these  cases  disappears  by  discharge  through  an  opening 
into  a  bronchus. 

Loomis  states  that  when  spontaneous  opening  occurs,  about  twenty 
per  cent  recover;  but  that  when  the  pus  has  been  removed  by  operative 
procedures,  only  about  twelve  per  cent  recover;  but  I  have  seen  quite  a 
series  of  cases  in  which  evacuation  of  the  pus  by  the  method  here  recom- 
mended has  been  followed  by  recovery  in  about  seventy-five  per  cent  of 
the  patients. 

Treatment. — Pus  in  the  pleural  cavity  must  be  removed.  To  this 
end  various  operations  have  been  advocated. 

Aspiration  of  the  cavity  repeated  two  or  three  times  has  in  a  few 
cases  proved  sufficient. 
•  L.  G.  Fiitterer,  of  Chicago,  reported  to  me  by  personal  letter  six  cases 
perfectly  cured  by  aspiration  of  the  chest  and  washing  out  of  the  cavity 
with  a  three-fourths  of  one  per  cent  solution  of  clove  oil  in  water  that 
had  been  filtered  and  thoroughly  boiled.  This  was  injected  and  drawn 
off  and  followed  by  a  permanent  injection  of  a  second  quantity  of  this 
solution  nearly  equal  in  amount  to  the  pus  first  evacuated. 

Another  method  of  treatment  is  by  pleurotomy.  An  incision  is  made 
in  the  axillary  region  between  the  fifth  and  ninth  ribs  and  parallel  to 
them;  double  drainage  tubes  are  inserted  and  a  Lister  dressing  is  ap- 
plied. A  convenient  apparatus  recommended  by  A.  T.  Cabot  (Cyclo- 
pedia of  the  Diseases  of  Children,  Keating,  Vol.  II,  p.  712,  1889)  is 
readily  made  from  a  piece  of  tubing'  cut  half  in  two,  folded  upon  itself 
and  held  in  place  through  a  shield  by  safety-pins. 

Still  others  advise  resection  of  the  ribs  either  subperiosteal  or  not,  and 
performed  with  various  incisions  and  miuor  points  of  technique. 

Authorities  differ  as  to  the  invariable  advisability  of  washing  out  the 
cavity.  Bowditch  {Medical  News,  January,  1889)  claims  that  in  two 
hundred  and  ninety-nine  operations  upon  two  hundred  and  fifty  patients 
he  found  it  necessary  to  wash  out  the  cavity  only  once,  and  he  considers 
it  dangerous.  De  Cerenville  (Schmidt's  Jahrbucher,  Band  218,  Heft  1)  re- 
ports six  cases  of  epilepsy  in  children,  following  mechanical  irritation  of 
the  pleural  surfaces,  as  in  irrigation,  sounding,  and  probing.  Equally 
high  authorities  favor  irrigation. 

A.  B.  Strong,  of  Chicago,  strongly  favors  resection  of  the  ribs,  and 
reports  thirteen  cases  (Chicago  Medical  Record,  October,  1801)  with  only 
one  death.  Of  these,  however,  twelve  were  acute  and  eight  were  in 
young  children  in  whom  the  prognosis  is  usually  favorable,  whatever 
method  of  evacuation  of  the  pus  is  adopted.  He  uses  large  drainage 
tubes  (Fig.  23)  well  adapted  for  the  purpose,  readily  made  and  easily  worn. 

W.  M.  Strickler,  of  Colorado  Springs,  Colorado  (Medical  Xews, 
May,  1887),  advocates  resection  of  the  fifth,  sixth,  and  seventh  ribs, 
thorough  digital  examination  of  the  cavity,  removal  with  the  fingers 


CHRONIC  PLEURISY. 


79 


of  all  fibrinous  masses,  separation  of  adhesions  if  necessary,  and  copiout 
hot-water  irrigation,  followed  by  daily  flushings.  He  reports  excellent 
results  in  five  adult  cases. 

Zimmerman  and  others  consider  siphon  drainage  as  the  most  effec- 
tive.    A  long,  aseptic  rubber  tube  is  passed  into  the  cavity  through  the 


I 


Fig.  23.— Cabot's  Drainage  Tubes. 


Fig.  23.— Strong's  Drainage  Tubes.    One-half  size. 


canula  of  a  large  trocar,  a  clamp  closing  the  outer  end  of  the  tube.  The 
canula  is  then  slipped  out,  the  tube  is  clamped  between  it  and  the  chest 
wall,  and  the  first  clamp  and  the  canula  are  removed.  Connected  to  this 
tube  is  a  glass  one  leading  through  a  rubber  stopper  to  the  bottom  of  a 
bottle  containing  some  antiseptic  solution. 

To  secure  a  constant  air-tight  joint  at  the  wound  in  thin  patients 
where  the  tissues  retract,  the  tube  may  pass  through  a  rubber  shield  bound 


Fig.  24.— Ingals''  Flat  Trocar.    One-half  size.    For  introducing  drainage  tubes  in  empyema. 

closely  to  the  chest.  Powell  (Canadian  Practitioner,  1887)  successfully 
treated  six  cases  by  siphon  drainage,  using  Nekton's  catheter  passed 
through  a  rubber  bandage  fastened  around  the  chest,  and  washed  out  the 
cavity  by  alternately  raising  and  lowering  the  bottle  containing  a  weak 
solution  of  carbolic  acid. 

With  a  single  exception,  I  have  never  found  resection  necessary.  The 
radical  operation  which  I  have  employed  with  much  satisfaction  for  many 
years  is  performed  by  means  of  a  broad,  flat  trocar  (Fig.  24)  sufficiently 
large  to  admit  the  passage  of  two  drainage  tubes  at  once.     If  an  ana?s- 


80  PULMONARY  DISEASES. 

thetic  is  thought  necessary,  nitrous-oxide  gas  may  be  advantageously 
used,  as  its  effects  are  quickly  over;  but  it  will  usually  be  sufficient  to 
inject  deep  into  the  intercostal  tissues,  as  well  as  just  beneath  the  skin, 
a  few  drops  of  a  four-per-cent  solution  of  cocaine  such  as  recommended 
for  local  anaesthesia  in  the  nose.  The  skin  having  been  made  thoroughly 
clean,  it  is  punctured  by  a  small  scalpel,  which  makes  an  incision  about 
a  quarter  of  an  inch  in  length,  the  point  of  the  trocar  is  entered  into 
this  incision,  and  then  the  instrument  is  plunged  boldly  into  the  chest. 
As  soon  as  the  stiletto  is  withdrawn,  the  thumb  of  the  operator  is  placed 
over  the  mouth  of  the  canula  to  prevent  the  escape  of  pus;  and  then  the 
tubes,  which  have  been  previously  prepared,  are  slipped  quickly  through 
the  canula  to  the  required  depth,  the  canula  is  withdrawn  and  the  tubes 
are  left  in  the  chest.  A  bit  of  sheet  rubber  about  three  inches  square, 
with  two  small  openings  near  the  centre  and  close  together,  is  now 
slipped  over  the  tubes  and  down  to  the  chest  wall.  Next,  a  section  of 
the  same  tubing  about  half  an  inch  in  length,  through  which  have  been 
tied  two  loops  of  stout  thread  each  about  an  inch  in  length,  is  passed 
over  a  canula  and  slipped  down  over  the  drainage  tube  to  the  chest  wall, 
where  it  is  forced  off  upon  the  drainage  tube  close  to  the  surface.  Both 
tubes  are  treated  alike,  and  through  the  loops  are  passed  long  strips  of 
adhesive  plaster,  by  which  they  are  bound  firmly  to  the  chest  wall. 

The  drainage  tube  is  now  perfectly  under  the  control  of  the  operator; 
it  cannot  possibly  slide  into  the  chest,  and  the  adhesive  straps  keep  it 
from  being  forced  out  a  few  days  later  when  the  tissues  about  it  have 
retracted.  The  section  of  sheet  rubber  placed  next  to  the  chest  wall 
acts  as  a  valve  preventing  air  from  entering  the  chest  at  least  for  the 
first  eight  or  ten  days;  that  is,  until  the  retraction  of  the  tissue  occurs 
about  the  tubing.  A  roller  bandage  is  applied  over  the  whole,  the  drain- 
age tubes  being  allowed  to  protrude  through  it.  In  preparing  the  drainage 
tube,  I  take  a  piece  of  ordinary  pure  gum  tubing  about  two  feet  in  length 
and  one-eighth  of  an  inch  in  calibre  and  cut  it  half  across  near  the 
middle;  it  is  then  folded  upon  itself,  one  of  the  tubes  is  perforated  in 
several  places  extending  about  three  inches  from  this  cut  end,  the  other 
in  a  couple  of  places,  extending  about  one  inch.  About  an  inch  and  a 
half  from  this  end  the  two  tubes  are  stitched  together  at  a  single  point 
with  strong  silk.  The  stitch  is  made  through  one  of  the  perforations 
and  knotted  within  the  tube;  then,  if  by  any  means  it  come  loose,  it  is 
likely  to  be  washed  out.  When  folded  upon  itself  and  fastened  in  this 
way,  one  of  the  tubes  is  cut  about  half  an  inch  shorter  than  the  other, 
so  that  the  operator  may  know  subsequently  which  tube  is  perforated  the 
greater  distance  from  the  end.  About  six  inches  from  the  end  of  the 
tube  which  is  passed  into  the  chest,  a  bit  of  thread  is  tied  closely  about 
it  as  a  mark,  in  order  that  during  the  operation  the  surgeon  may  know 
how  far  it  has  been  passed  through  the  canula.  Finally,  the  outer  ends 
of  the  tubes  are  tied  tightly,  and  the  whole  is  made  aseptic  by  soaking 
in  a  strongly  carbolized  solution.  By  thus  closing  the  ends  of  the  tubes, 
we  are  enabled  to  slip  them  through  the  canula,  withdraw  the  latter,  and 


CHRONIC  PLEURISY. 


81 


| 2s 


complete  the  operation  even  when  the  chest  is  much  distended,  without 
the  escape  of  more  than  one  or  two  ounces  of  pus. 

After  the  dressings  are  completed,  the  drainage  tubes  may  be  bent 
upon  themselves  to  seal  them  hermetically,  while  the  ends  are  opened 
and  connected  by  short  glass  tubes  to  longer  rubber  tubes,  through  which 
the  cavity  may  be  washed  or  drained  according  to  indications.  It  has 
been  my  custom  to  wash  out  the  pleural  sac  immediately  with  an  anti- 
septic solution,  and  to  have  the  wash- 
ing repeated  afterward  once  or  r-j  ,-  -"-  ■  -  -j'-v'^ 
twice  daily  for  a  couple  of  weeks,  and  '  '  _ 
subsequently  less  frequently  until 
the  sac  is  obliterated.  This  solution 
should  be  used  at  a  temperature  of 
101°  F.  Between  the  washings  the 
ends  of  the  tubes  may  be  bent  upon 
themselves  and  tied,  or  they  may  be 
left  hanging  in  a  bottle  containing 
some  antiseptic  solution,  as  thought 
best.  When  the  patient  is  able  to 
walk  about,  I  usually  allow  drainage 
to  go  on  constantly  into  a  bottle  which 
the  patient  carries  in  his  pocket. 
In  cases  of  empyema  which  have 
lasted  for  a  long  time,  it  is  very  im- 
portant that  about  the  fifth  or  sixth 
week  after  the  operation  the  phy- 
sician should  ascertain  whether  the 
cavity  is  decreasing  in  size,  which 
can  be  easily  done  by  measuring 
from  time  to  time  the  quantity  of  fluid  required  to  fill  it.  Usually  the 
pleural  sac  rapidly  contracts  until  it  will  not  hold  more  than  four  or  five 
ounces;  but  after  this,  especially  in  adult  cases  of  long  standing,  the  con- 
traction may  be  very  slow.  Here  it  becomes  necessary  to  use  stimulat- 
ing injections,  such  as  aqueous  solutions  of  zinc  sulphate,  gr.  ij.  to  iv. 
ad  3  i.;  iron  sulphate  double  this  strength;  compound  solution  of  iodine, 
3  ss.  to  3  i.  ad  §  i. ;  or  copper  sulphate,  gr.  v.  to  gr.  xx.  ad  §  i.  If 
iodine  is  used  it  will  attack  the  drainage  tubes  so  that  they  must  be 
renewed  every  two  or  three  days.  Hydrogen  peroxide,  the  commercial 
solution  diluted  with  an  equal  volume  of  water,  has  been  highly  recom- 
mended to  check  suppuration,  and  a  solution  of  the  oil  of  cloves  or 
emulsion  of  iodoform  may  be  used  for  the  same  purpose.  When  the 
cavity  has  so  far  contracted  as  to  hold  not  more  than  two  or  three 
drachms,  the  drainage  tubes  may  be  withdrawn  about  half  an  inch,  left 
in  this  position  for  two  or  three  days,  then  withdrawn  as  much  farther, 
and  so  on  until  they  are  out  of  the  pleural  cavity,  when  the  external 
wound  readily  closes. 
6 


Fig.  25. — Ingals'  Drainage  Tubes  for 
Empyema.  A,  sheet  rubber ;  B,  retaining 
apparatus. 


82  PULMONARY  DISEASES. 

The  aim  in  the  treatment  of  empyema  is  to  give  free  exit  for  pus, 
and  secure  obliteration  of  the  pleural  sac  by  agglutination  of  its  walls. 
Hence  we  encourage  as  far  as  possible  the  expansion  of  the  lung,  in 
some  cases  allowing  the  ribs  to  fall  in.  by  resection,  and  bring  the  pleural 
surfaces  together. 

The  importance  of  careful  medical  and  general  treatment  adapted  to 
the  improvement  of  the  patient's  condition  need  hardly  be  emphasized. 

PECULIAR    LOCAL    FORMS    OF    PLEURISY. 

The  following  forms  of  pleurisy,  though  not  entitled  to  be  considered 
as  distinct  varieties,  need  some  special  consideration : 

Circumscribed  pleurisy  usually  occurs  during  the  course  of  phthisis, 
and  is  responsible  for  many  of  the  acute  pains  suffered  by  consumptives. 
This  inflammation  is  generally  limited  to  the  small  portion  of  pleura 
investing  the  lung  where  the  lesions  are  superficial.  The  signs  indi- 
cating this  condition  are  some  variety  of  friction  sound,  or  a  dry,  creak- 
ing sound,  probably  due  to  old  adhesions. 

Pleurisy  of  the  apex,  unassociated  with  phthisis,  is  said  by  J.  Burney 
Yeo  to  be  a  frequent  disease,  which  he  believes  to  be  the  cause  of  many 
coughs,  usually  called  hysterical  or  stomach  coughs.  He  has  observed 
it  principally  in  women  who  have  been  accustomed  to  wear  low-necked 
dresses.  Its  chief  symptom  is  a  harsh,  dry,  shallow,  or  incomplete  cough, 
occurring  in  a  person  apparently  in  good  health. 

The  only  physical  sign  to  be  detected  is  friction  limited  to  the  supra- 
clavicular region,  or  to  the  upper  third  of  the  scapular  region. 

Diaphragmatic  pleurisy  or  inflammation  of  the  pleura  covering  the 
diaphragm  is  not  easily  detected.  According  to  Xoel  Gueneau,  the  fol- 
lowing symptoms  render  its  diagnosis  more  precise.  Besides  the  pain 
elicited  by  percussion  over  the  base  of  the  chest  on  the  affected  side,  there 
is  a  point  of  hyperesthesia,  due  to  irritation  of  the  phrenic  nerve,  found 
at  the  intersection  of  two  lines,  one  of  which  corresponds  to  the  border 
of  the  sternum,  and  the  other,  perpendicular  to  it,  follows  and  prolongs 
the  border  of  the  ribs.  At  the  same  time  there  is  hyperesthesia  found 
between  the  sternal  attachments  of  the  sterno-cleido-mastoid  muscles, 
and  pain  in  the  shoulder  and  in  the  infra-clavicular  region  of  the  same 
side.  These  are  reflexes  from  irritation  of  the  phrenic  nerve.  Neuralgia 
of  the  last  intercostal  nerve  is  also  frequently  present,  and  there  is  likely 
to  be  increased  obliquity  of  the  last  rib  on  the  affected  side,  and  immo- 
bility of  the  hypochondrium.  If  the  inflammation  is  on  the  right  side, 
the  liver  is  usually  slightly  depressed. 

Percussion  gives  a  high-pitched  note  over  a  narrow  space,  correspond- 
ing to  the  lower  margin  of  the  lung  contiguous  to  the  effusion. 

On  auscultation,  the  vesicular  sound  at  the  level  of  the  collection  of 
liquid  is  usually  feeble,  and  accompanied  with  crepitant  or  mucous 
rales.     Weakness  of  the  inspiratory  sound  and  prolonged  expiration  may 


PECULIAR  FORJIS   OF  PLEURISY.  83 

exist  over  the  whole  lung,  due  to  compressiou  of  the  bronchi  by  enlarged 
glands,  which  are  said  ordinarily  to  accompany  this  disease. 

Multilocular  pleurisy  is  rarely  observed.  In  1854,  Wintrich  wrote 
that  it  was  impossible  to  distinguish,  in  the  living  subject,  between  uni- 
locular, bilocular,  and  multilocular  pleurisy,  and  this  proposition  is  still 
generally  accepted;  but  in  a  communication  to  the  Academie  de  Medi- 
cine, of  Paris,  in  1879,  Jaccoud  declared  the  diagnosis  possible  when  the 
following  groups  of  signs  are  found  coincidently  with  the  ordinary 
symptoms  and  signs  of  pleurisy.  He  has  observed  two  distinct  semeio- 
logical  types  of  the  affection. 

In  the  first,  added  to  the  ordinary  signs  of  complete  pleuritic  effu- 
sions, the  vocal  fremitus,  though  lost  over  every  other  portion  of  the 
affected  side,  is  found  to  be  preserved  along  a  line  running  forward  from 
the  spinal  column,  in  a  more  or  less  regular  semicircular  course,  toward 
the  sternum,  at  a  variable  height.  Vocal  Resonance  and  bronchial  respi- 
ration are  heard  in  the  same  locality,  though  wanting  everywhere  else. 

This  line  indicates  the  position  of  the  band  of  pleuritic  adhesion 
dividing  the  pleural  sac  into  two  cavities.  In  these  cases,  he  has  found 
in  the  infra-clavicular  region  feeble  and  distant  respiratory  murmur  and 
voice-sounds,  with  no  tympanitic  resonance. 

In  the  second  type,  vocal  fremitus,  though  more  or  less  enfeebled,  is 
obtained  over  the  whole  effusion,  excepting  sometimes  a  narrow  zone 
of  the  breadth  of  one  or  two  fingers,  at  the  lower  posterior  part  of  the 
chest.  Marked  bronchial  respiration  and  bronchophony  are  also  found 
over  the  fluid,  with  perfect  flatness  on  percussion,  and  no  tympanitic 
resonance  under  the  clavicle.  In  two  cases  he  has  been  able  to  locate 
the  fundamental  partitions,  by  finding  one  or  two  zones  where  the 
vibrations  were  manifestly  stronger  than  in  other  localities.  The  value 
of  this  diagnosis  depends  upon  the  proposition  apparently  established 
by  Jaccoud's  observations,  that  thoracentesis  is  not  well  borne  in  multi- 
locular pleurisy,  but  that  it  seems  rather  to  add  greatly  to  the  patient's 
danger.  The  essential  points  in  the  differential  diagnosis  between  ex- 
tensive pleuritic  effusions  of  the  unilocular,  bilocular,  and  multilocular 
types  are  shown  in  the  following  table : 

Unilocular  pleurisy.       Bilocular  pleurisy.    Multilocular   pleurisy. 

Palpation. 
Loss  of  vocal  fremitus.  Vocal  fremitus  preserved  Vocal  fremitus,  though 
on  a  line  corresponding  enfeebled,  is  present  over 
with  the  band  of  adhesion,  the  whole  of  the  affected 
though  lost  above  and  be-  side,  excepting  a  small 
low  this  line.  zone  at  the  base.     Vocal 

fremitus  is  occasionally 
well  marked  in  one  or  two 
limited  zones  correspond- 
ing to  bands  of  adhesion. 


S4 


PULMONARY  DISEASES. 


Unilocular  pleurisy. 

Usually  tympanitic  res- 
onance under  the  clavi- 
cle. 

Absence  of  respirator}' 
murmur  and  vocal  reso- 
nance, excepting  over  the 
compressed  lung  in  the 
upper  part  of  the  thorax. 


BlLOCULAR  PLEURISY. 

Percussion. 
Flatness  over  the  whole 
chest  ;  no  tympanism. 

Auscultation. 
Bronchial  respiration 
and  bronchophony  heard 
over  a  line  corresponding 
to  the  pleuritic  band,  but 
wanting  in  other  places,. 
except  over  the  apex, 
where  they  are  indistinct. 


MULTILOCULAR  PLEURISY. 

Flatness  over  the  whole- 
chest;  no  tympanism. 


Bronchial  respiration 
and  bronchophony  mark- 
ed over  the  seat  of  the 
whole  effusion. 


HYDROTHORAX. 

Hydrothorax  is  a  term  applied  to  the  presence  in  the  pleural  cavity  of 
a  dropsical  effusion,  which  is  non-inflammatory  in  character,  thin,  clear, 
yellow,  or  greenish.  It  has  a  low  specific  gravity,  contains  relatively 
little  albumin,  and  coagulates  less  readily  than  an  inflammatory  effusion. 
The  affection  is  usually  bilateral,  but  may  be  confined  to  one  side. 

Etiology. — Hydrothorax  may  arise  from  any  condition  which  im- 
pedes venous  circulation,  producing  extensive  passive  congestion,  as  heart 
disease,  notably  mitral  affection;  diseases  of  the  liver  or  kidneys;  pres- 
sure of  tumors  and  the  like  and  venous  thrombosis;  it  may  also  be  the 
result  of  malignant  disease,  chronic  blood-poisoning,  exhausting  dis- 
charges, or  other  morbid  conditions  producing  general  hydremia. 

The  symptoms,  of  which  dyspnoea  is  most  marked,  come  on  insidi- 
ously and  are  due  to  pressure  of  the  fluid. 

The  signs  will  be  similar  to  those  of  an  inflammatory  effusion. 

Diagnosis  will  be  based  upon  the  signs  and  symptoms  of  the  cau- 
sative disease,  the  absence  of  inflammatory  symptoms,  the  character  of 
the  fluid,  and  its  usual  bilateral  position. 

Prognosis  will  depend  upon  the  cause. 

Treatment  will  be  directed  to  the  primary  morbid  condition  and  to 
the  immediate  relief  of  the  lung  by  aspiration. 


PNEUMOTHORAX. 

Pneumothorax  consists  of  a  collection  of  air  or  gas  in  the  pleural  sac, 
resulting  from  ])erforation  of  the  pleura  or  from  decomposition  of  pleu- 
ritic effusions  (Fig.  26). 

Etiology. — Air  may  enter  the  pleural  cavity  through  a  traumatic 
opening  in  the  chest  wall;  through  communication  established  with  the 
stomach  or  oesophagus  by  ulceration  or  rupture;  through  openings  into 
the  lung  from  exploratory  puncture,  fracture  of  the  ribs,  or  ulceration 
due  to  phthisis,  empyema,  abscess  of  a  bronchial  gland,  or  gangrene;  or 


PNEUMO-HYDROTHORAZ.  85 

through  rupture  of  an  emphysematous  sac.     About  ninety  per  cent  of  all 
cases  are  of  tubercular  origin. 

Symptomatology. — The  usual  symptoms  are  sudden  acute  pain  in 
the  side,  with  severe  dyspnoea  and  lividity  of  the  lips  and  face;  great 
prostration,  accompanied  with  anxiety  of  countenance  ;  a  clammy  sur- 
face, palpitation,  accelerated  pulse,  and  in  some  cases  collapse  followed 
by  death  within  a  few  hours.  In  other  cases  the  symptoms  are  mani- 
fested insidiously,  only  becoming  marked  when  considerable  fluid  accu- 
mulation has  followed  the  entrance  of  air.  This  is  the  case  in  pneumo- 
thorax from  emphysema.  If  it  result  from  phthisis,  the  symptoms, 
especially  pain,  are  very  marked. 

The  most  important  signs  are  diminished  movement  and  enlargement 
of  the  affected  side;  tympanitic  resonance;  respiratory  murmur  feeble 
or  amphoric  in  character  or  wanting. 

Inspection  and  mensuration  reveal  distention  of  the  affected  side, 
diminution  or  loss  of  the  respiratory  movements,  with  widening,  and 
sometimes  bulging  of  the  intercostal  spaces. 

Palpation  shows  the  vocal  fremitus  feeble  or  wanting,  and  the  apex 
beat  of  the  heart  displaced  toward  the  sound  side. 

.  By  percussion,  tympanitic  or  amphoric  resonance  is  obtained  over  the 
collection  of  air.  When  distention  of  the  side  is  extreme,  the  adjacent 
organs  are  displaced,  and  the  tympanitic  resonance,  somewhat  muffled 
and  modified  in  quality,  may  be  obtained  for  a  considerable  distance 
beyond  the  normal  limits  of  the  pleura. 

Exceptional. — Occasionally  when  the  tension  is  very  great,  the  percussion 
note  is  so  muffled  as  to  seem  almost  dull.  The  bell  sound  may  be  obtained  by 
percussion  with  two  coins  on  one  side  of  the  cavity  while  the  ear  is  placed 
opposite. 

In  auscultation,  the  respiratory  murmur  is  feeble  or  absent  according 
to  the  amount  of  air.  The  vocal  sounds  are  altered  in  like  manner. 
The  respiratory  murmur  on  the  sound  side  is  exaggerated.  The  heart 
sounds  are  feebly  transmitted  through  the  collection  of  air.  Bronchial 
breathing  may  be  heard  over  the  compressed  lung,  in  the  inter-scapular 
space,  and  usually  over  the  apex  anteriorly.  Amphoric  respiration  and 
voice  are  also  obtained  when  a  bronchial  tube  connects  freely  with  the 
cavity  of  the  pleura.  The  differential  diagnosis  between  pneumothorax 
and  emphysema,  the  only  disease  with  which  it  is  likely  to  be  confounded, 
will  be  given  under  the  latter. 

PNEUMO-HYDROTHORAX. 

Pneumo-hydrothorax  signifies  a  collection  of  both  fluid  and  air  in 
the  pleural  sac.  When  the  former  becomes  purulent,  as  is  usually  the 
case,  the  condition  is  termed  pyo-pneumothorax.  As  the  effusion  of 
fluid  is  almost  sure  to  follow  in  a  few  hours  after  the  admission  of  air 


bo 


PULMONAR  Y  DISEASES. 


into  the  pleura,  the  signs  and  symptoms  of  this  disease  and  of  pneumo- 
thorax are  usually  considered  together,  but  the  presence  of  both  air  and 
fluid  in  the  pleural  cavity  causes  some  signs  which  are  not  found  in 
pneumothorax.  The  splashing  sound  obtained  by  succussion  is  diag- 
nostic.    Metallic  tinkling  is  also  found  in  many  instances  (Fig.  20). 

Inspection,  palpation,  and  mensuration  furnish  the  same  signs  as 
in  pneumothorax  or  in  extensive  pleuritic  effusions.  There  is  absence 
of  vocal  fremitus,  and  displacement  of  the  heart  and  adjacent  organs, 
with  distention  of  the  side  and  loss  of  motion. 

On  percussion,  tympanitic  resonance  is  obtained  over  the  air  in  the 
upper,  and  flatness  over  the  fluid  in  the  lower,  part  of  the  chest.     The 


Amphoric    sounds,  I 
Metallic  tinkling,    f 


Flatness. 


Fig  .  26.— Pneumo-Hydrothorax.    Right  lung  compressed  by  air  and  fluid.    Heart  crowded  far 

to  the  left. 


line  of  flatness  corresponding  to  the  surface  of  the  fluid  changes  with 
the  position  of  the  patient.  Tympanitic  resonance  is  not  infrequently 
transmitted  a  short  distance  beyond  the  limits  of  the  pleura,  and  even 
below  the  surface  of  the  fluid,  so  that  if  only  a  small  effusion  is  present 
this  sign  may  be  heard  over  the  entire  chest,  and  thus  the  presence  of 
fluid  escape  our  notice.  Amphoric  resonance  is  sometimes  heard  over 
the  upper  part  of  the  chest. 

Upon  auscultation  below  the  level  of  the  fluid,  the  respiratory  mur- 
■nur  is  absent  or  very  feeble  and  distant.  Above  this  level  it  may  be  the 
same,  or  amphoric  respiration  may  be  heard.  This  latter  may  be  limited 
to  a  small  space  near  the  point  of  perforation,  which  is  likely  to  be 
located  just  in  front  of  the  angle  of  the  fourth  or  fifth  rib.  Amphoric 
respiration  may  disappear  and  reappear  again  during  the  course  of  the 
disease,  in  consequence  of  the  variation  in  the  amount  of  fluid  from  day 
to  day. 


PNEUMO-HYDROTHORAA'.  87 

Usually  bronchial  respiration  is  heard  over  the  compressed  lung, 
where  it  lies  against  the  spinal  column. 

The  signs  of  phthisis,  which  in  nine  cases  out  of  ten  precede  those  of 
pneumothorax,  are  frequently  found  at  the  apex  of  the  lung  on  the 
opposite  side.  Metallic  tinkling  is  one  of  the  signs  of  this  disease.  It 
may  result  from  agitation  of  the  fluid  in  coughing.  The  splashing 
sound  obtained  on  succussion  is  characteristic.  Vocal  resonance  is  feeble 
or  wanting,  or  amphoric,  upon  the  affected  side.  The  percussion  reso- 
nance and  the  respiratory  murmur  upon  the  sound  side  are  exaggerated. 

Diagnosis. — Pneumothorax  and  pneumo-hjdrothorax  are  not  likely 
to  be  mistaken  for  other  diseases,  though  they  are  said  to  be  closely 
simulated  when  there  is  complete  catarrhal  obstruction  of  the  main 
bronchus  on  one  side.  They  may  possibly  be  mistaken  for  emphysema, 
chronic  pleurisy,  or  diaphragmatic  hernia. 

Comparison  with  emphysema  presents  the  following  distinctive  fea- 
tures : 

Pneumothorax  and   pneumo-hydro-  Emphysema, 

thorax. 

Inspection. 
Prominence  or  bulging  of  one  side,  Prominence  of  the  anterior  superior 

with  loss  of  movement,  especially  at  portion  of  the  chest,  usually  upon  both 
the  lower  part  of  the  chest,  but  no  fall-  sides,  with  a  characteristic  lifting 
ing  in  of  the  inferior  ribs  or  intercostal  movement  of  the  upper  part  and  fall- 
spaces  during  inspiration.  ing  in  of  the  lower  ribs  and  intercostal 

spaces  during  inspiration,  with  fre- 
quently permanent  contraction  of  the 
lower  part  of  the  chest. 

Percussion. 

Tympanitic  resonance  over  the  up-  Vesiculotympanitic  resonance  over 

per  part  of  the  chest  with  flatness  over  the  entire  lung,  but  most  marked  at 

the  fluid,  the  line  of  flatness  varying  the  superior  portions ;  no  flatness  be- 

with  changes  in  the  patient's  position.  low.     The  heart  may  be   covered  by 

The  heart  is  displaced  to  the  right  or  lung  tissue,  but  it  is  not  greatly  dis- 

left,  according  to  the  seat  of  the  dis-  placed.     The  signs  are  usually  found 

ease.     Nearly  always  these  signs  are  on  both  sides. 
found  on  one  side  only. 

Auscultation. 

Respiratory   murmur  feeble   or  ab-  Respiratory  murmur  usually  feeble 

sent ;  if  heard,  the  expiratory  murmur  and  generally  associated  with  bronchial 

is  of  normal  duration,  unless  prolonged  rales.      The  expiratory  sound  is  pro- 

by  consolidation  of  the  lung,  in  which  longed  and  low  pitched.     The  respira- 

case  it  will  be  high  pitched.     Amphoric  tory  sounds  are  sometimes  harsh  and 

respiration  and  voice  are  observed  if  a  tubular,  but  never  amphoric.     No  me- 

bronchial  tube  connects  freely  with  the  tallic  tinkling, 
pleural  cavity.     Metallic  tinkling. 

Succussion. 
Splashing  sounds  if  fluid  is  present.  No  splashing  sound. 


88  PULMONARY  DISEASES. 

These  diseases  can  be  easily  distinguished  from  chronic  pleurisy  by 
the  physical  signs  obtained  on  percussion  and  auscultation.  On  inspec- 
tion, palpation,  and  mensuration  the  signs  are  similar. 

Pneumothorax  and  pneumo-hydro-  Chronic  pleurisy, 

thorax. 

Percussion. 
Tympanitic  resonance  over  the  up-  Tympanitic  resonance,  if  heard  atall, 

per  portion  of  the  chest,  flatness  over        is  limited  to  a  small  space  at  the  apex 
the  fluid.  of  the  lung,  usually  immediately  be- 

neath the  clavicle  ;  flatness  over  the 
remainder  of  the  affected  side. 

Auscultation. 
Often     amphoric     respiration     and  Never  amphoric  respiration  or  voice, 

voice. 

Diaphragmatic  hernia  is,  fortunately,  a  rare  disease.  It  possesses 
many  symptoms  and  signs  in  common  with  pneumothorax,  like  which  it 
causes  distention  of  one  side,  displacement  of  the  heart,  diminished 
motion,  tympanitic  resonance,  and  feeble  or  suppressed  respiration  with 
metallic  tinkling.  The  differential  diagnosis  depends  mainly  upon  the 
history  and  the  symptoms,  as  seen  from  the  following  table: 

Pneumothorax.  Diaphragmatic  hernia. 

History  and  Symptoms. 

Usually  follows  phthisis  or  accidental  Often  congenital ;  at  times  dyspnoea 

perforation  of  pleura  ;    the    dyspnoea        comes  on  suddenly,  and  as  suddenly 
may  come  on  suddenly  or  gradually.  disappears. 

Auscultation. 
Amphoric  respiration  and  metallic  No  amphoric  respiration,   and    the 

tinkling.  metallic  tinkling  occurs  independently 

of  the  respiratory  movements,  and  is 
associated  with  rumbling  of  gas  in  the 
stomach  or  intestines,  which  usually 
form  the  contents  of  the  hernia. 

Prognosis. — Pneumothorax  without  pleuritis  is  rare,  but  when  it 
does  occur  recovery  not  infrequently  takes  place.  The  prognosis  in 
pyo-pneumothorax  is  very  unfavorable.  Death  often  occurs  within  a 
few  hours  or  at  most  within  a  week  or  two.     Rarely  patients  recover. 

Treatment. — Pneumothorax  and  pneumo-hydrothorax  call  for  es- 
sentially .the  same  treatment.  At  first  an  opiate  should  be  administered 
to  relieve  pain.  When  fluid  has  collected  and  dyspnoea  is  great,  free 
drainage  is  advisable,  especially  if  the  fluid  has  become  purulent;  subse- 
quently the  case  should  be  treated  in  the  same  manner  as  empyema. 

Potain  recommends  replacing  the  fluid  and  air  by  sterilized  air,  and 
reports  favorably  (Gazette  des  Hopitaux,  April,  1889). 


CHAPTEE    VII. 

PULMONABY   DISEASES.— Continued. 

BRONCHITIS. 

Bronchitis  is  an  inflammation  of  the  membrane  lining  the  bron- 
chial tubes.  It  affects  both  sides  at  the  same  time,  and  is  therefore 
called  a  bilateral  disease.  Five  varieties  of  bronchitis  are  recognized, 
viz.,  acute,  subacute,  chronic,  capillary,  and  plastic  bronchitis. 

ACUTE    AND    SUBACUTE    BRONCHITIS. 

The  symptoms  and  the  signs  of  acute  and  subacute  bronchitis  are 
substantially  the  same,  except  that  in  the  latter  variety  they  are  less 
marked. 

Anatomical  and  Pathological  Characteristics. — The  morbid 
peculiarities  in  acute  bronchitis  are  those  of  acute  catarrhal  inflamma- 
tion affecting  the  larger  bronchi.  There  is  congestion,  thickening,  and 
softening  of  the  mucous  membrane;  slight  exfoliation  of  superficial 
epithelial  cells,  and  hypersecretion  of  thin  transparent  mucus,  frothy 
from  admixture  of  air.  This  gradually  becomes  translucent,  and  finally 
yellow  and  viscid  as  more  leucocytes  escape  from  the  engorged  vessels. 
Slight  ecchymoses  may  appear  in  severe  cases,  and  the  expectoration  may 
show  minute  points  of  blood.  This  affection,  usually  confined  to  the 
larger  tubes  in  adults,  has  a  tendency  in  children  and  the  aged  to  involve 
the  capillary  bronchi.  The  same  conditions  are  present  in  subacute 
bronchitis,  but  less  marked. 

Etiology. — Old  people  and  infants  and  those  debilitated  by  disease 
or  vicious  habits  or  subjects  of  the  gouty  or  rheumatic  diathesis  are 
most  disposed  to  attacks  of  bronchitis,  especially  if  exposed  to  improper 
hygienic  conditions,  whether  of  poor  ventilation,  defective  drainage,  or 
deficient  food  and  clothing.  It  is  more  prevalent  in  climates  exhibiting 
frequent  and  sudden  atmospheric  changes  in  humidity  and  temperature. 
Exposure  to  cold,  especially  when  the  body  is  overheated,  or  to  exces* 
sive  heat  in  a  badly  ventilated  room  is  a  frequent  cause.  Inhalation  of 
irritating  gases,  particles  of  dust,  or  larger  solid  bodies  frequently  gives 
rise  to  bronchial  inflammation.  The  occasional  occurrence  of  the  dis- 
ease in  seeming  epidemics  also  suggests  as  the  cause  in  some  cases  a 
micro-organism. 

Symptomatology. — Bronchitis  is  ushered  in  sometimes  with  a  chill; 
usually  with  pain  in  the  back  and  extremities,  attended  by  a  sensation 


90  PULMONARY  DISEASES. 

of  tightness  or  constriction  in  the  chest,  soreness  beneath  the  sternum,  a 
harsh  cough  and  frothy  expectoration  sometimes  streaked  with  blood. 

The  most  important  signs  are  absence  of  dulness  and  the  presence  of 
large  and  small,  dry  or  moist  rales  on  both  sides  of  the  chest  (Fig.  17). 

Inspection  in  acute  bronchitis  shows  the  chest  movemeuts  normal  or 
somewhat  accelerated. 

Upon  palpation,  the  vocal  fremitus  is  normal.  If  there  is  considera- 
ble secretion  in  the  tubes,  bronchial  fremitus  will  be  obtained,  especially 
in  children. 

Exceptional. — In  a  few  cases  the  movements  are  deficient  in  those  parts  of 
the  chest  supplied  by  bronchi  that  are  partially  occluded  by  a  collection  of  the 
bronchial  secretions. 

On  percussion,  the  resonance  is  normal. 

Exceptional. — In  some  cases  dulness  is  found,  especially  over  the  lower  por- 
tion of  the  chest,  due  to  accumulation  of  the  fluid  secretions.  This  dulness, 
however,  may  be  removed  by  coughing  and  free  expectoration. 

By  auscultation  in  subacute  bronchitis  we  frequently  hear  simply  a 
harsh  and  somewhat  bronchial  sound  without  rales.  In  acute,  and  in 
many  cases  of  subacute  bronchitis,  sonorous  and  sibilant  rales  (Fig.  7) 
are  obtained  in  the  early  part  of  the  disease,  and  the  vesicular  mur- 
mur is  more  or  less  obscured  by  these  signs.  After  from  twenty-four  to 
forty-eight  hours,  the  secretions  from  the  mucous  membrane  become 
abundant,  and  then  the  dry  give  place  to  large  and  small,  moist,  mucous 
rales.  The  intensity  of  these  rales  varies;  sometimes  they  are  feeble,  at 
other  times  they  may  be  heard  at  quite  a  distance  from  the  chest. 
These  signs  are  seldom  continuous.  Often  they  are  heard  during  a  few 
respirations,  and  are  then  displaced  by  deep  inspiration  or  by  forced 
expiration  or  cough.  Mucous  niles,  even  when  numerous,  may  some- 
times be  entirely  removed  by  free  expectoration. 

Some  of  the  bronchial  tubes  may  become  so  filled  with  mucus  as 
greatly  to  diminish  the  intensity  of  the  vesicular  murmur,  or  even  to 
suppress  it  in  those  portions  of  the  lung  supplied  by  the  occluded  bron- 
chus. 

Exceptional. — If  the  disease  affect  the  smaller  tubes,  the  vesicular  murmur 
may  be  inaudible  over  the  entire  chest. 

Vocal  resonance  is  not  altei'ed. 

CHRONIC    BRONCHITIS. 

Anatomical  and  Pathological  Characteristics. — Continued 
inflammation  of  the  bronchial  mucous  membrane  produces  thickening 
and  irregularity  of  its  surface.  The  surface  is  occasionally  paler  than 
normal  and  of  a  grayish  color,  but  is  usually  of  a  deep  pink  or  red  and 
sometimes  of  a  purple   hue.     The  congestion  may  be  diffused  or  in 


ACUTE  BRONCHITIS.  91 

patches,  and  the  surface  may  be  marked,  by  numerous  ecchymoses.  The 
muciparous  glands  become  swollen,  and  their  secretions  become  thin  and 
profuse  or  viscid  and  scanty,  partially  plugging  the  mouths  of  the  ducts. 
These  secretions  may  be  serous,  muco-purulent,  or  purulent,  sometimes 
also  fetid.  The  superficial  epithelial  cells  degenerate  and  exfoliate  to 
some  extent,  and  rarely  small  ulcerations  occur.  The  elastic  longitudi- 
nal fibres  and  muscular  coat  of  the  bronchial  wall  become  hypertrophied, 
the  latter  finally  undergoing  fatty  degeneration.  With  loss  of  muscular 
tone  and  elasticity,  bronchial  dilatation  may  occur;  in  the  larger  tubes 
the  soft  parts  may  bulge  out  between  the  cartilages,  forming  sacculi  in 
which  secretions  tend  to  collect  and  undergo  putrefaction.  The  carti- 
laginous rings  sometimes  become  calcified.  As  the  process  extends,  the 
outer  fibrous  coat  suffers  hypertrophy,  perhaps  followed  by  peribron- 
chitis with  progressive  induration,  contraction  and  diminution  in  the 
calibre  of  the  smaller  bronchi.  These  morbid  processes  may  result  in 
asthma,  bronchiectasis,  emphysema,  fibroid  phthisis,  lobular  pneumonia, 
or  dilatation  of  the  right  ventricle  causing  general  venous  conges- 
tion with  consequent  derangements  of  the  gastro-intestinal  and  renal 
systems. 

Etiology. — Chronic  bronchitis  occurs  most  frequently  in  those  of 
middle  age  or  advanced  life,  but  occasionally  in  children.  Generally 
malnutrition  referable  to  a  gouty  or  rheumatic  diathesis  or  to  the 
cachexia  of  chronic  alcoholism,  syphilis,  or  malaria  is  ultimately  accoun- 
table. 

Not  infrequently,  however,  some  pulmonary,  cardiac,  hepatic,  or  renal 
disorder,  producing  chronic  pulmonary  venous  congestion,  is  the  predis- 
posing cause.  The  exciting  causes  are  those  of  acute  bronchitis,  succes- 
sive and  obstinate  attacks  of  which  are  invited  by  the  constitutional 
bias. 

Kegarding  the  cause  of  the  putrid  condition  sometimes  developed  in  chronic 
bronchitis,  Josef  Lumniczer  {Wiener  med.  Presse,  May,  1889)  has  shown  that  the 
decomposition  is  probably  due  to  a  short  curved  bacillus,  one  and  one  half  micro- 
millimeters  in  length,  easily  stained  with  aniline  and  cultivated  at96.8°-100. 4°  F., 
when  it  develops  the  peculiar  fetid  odor  characteristic  of  the  disease  in  man  and 
the  lower  animals. 

Symptomatology. — The  most  constant  symptoms  are  cough  and  ex- 
pectoration, the  character  of  which  varies  greatly  according  to  the  course 
of  the  inflammation,  its  cause,  and  the  peculiarity  of  the  individual.  In 
severe  cases  and  those  of  long  standing,  dyspnoea  and  labored  breathing 
become  prominent  symptoms,  and  sometimes  there  is  complaint  of  a 
feeling  of  soreness  over  the  larger  bronchi.  Mild  cases  are  characterized 
by  slight  or  moderate  cough  with  some  muco-purulent  expectoration. 

The  so-called  winter  cough,  almost  or  quite  absent  in  summer  but 
recurring  with  the  return  of  cold  weather,  may  be  mild  at  its  beginning, 
but  is  apt  to  increase  in  severity  from  year  to  year. 


92  PULMONARY  DISEASES. 

In  other  subjects  of  bronchitis,  cough  and  expectoration  are  more 
constantly  present,  but  are  variable  in  character.  In  certain  cases,  aptly 
termed  bronchorrhcea,  expectoration  is  very  profuse,  amounting  some- 
times even  to  two  quarts  in  twenty-four  hours,  more  or  less  serous  in 
quality,  but  occasionally  purulent.  On  the  other  hand,  in  so-called 
dry  catarrh,  expectoration  is  scanty  and  viscid;  small,  tough,  trans- 
lucent masses  are  expelled  with  extreme  difficulty  during  severe  par- 
oxysms of  cough  accompanied  with  great  muscular  effort,  reflex  laryn- 
geal spasm,  choking,  venous  congestion  of  the  face  and  neck,  and  perhaps 
vomiting. 

The  signs  of  chronic  bronchitis  differ  from  those  of  the  acute  affec- 
tion principally  in  the  greater  abundance  of  mucous  rales  and  in  the 
scarcity  of  dry  rales. 

Diagnosis. — The  different  varieties  of  bronchitis  may  be  readily 
distinguished  from  each  other  by  the  history.  They  are  liable  to  be 
mistaken  for  asthma,  emphysema,  pulmonary  hemorrhage,  and  phthisis. 

From  asthma,  bronchitis  is  distinguished  by  the  symptoms  and  by 
the  history.  The  spasmodic  character  of  asthma,  its  sudden  appearance, 
the  great  dyspncea,  and  the  history  of  former  attacks  are  sufficient  to 
establish  the  diagnosis. 

The  physical  signs  in  these  two  diseases  differ  rather  in  degree  than 
in  kind,  as  shown  in  the  following  table: 

Bronchitis.  Asthma. 

In  the  early  stage,  dry  rales,  compar-  During  the  paroxysm,  sonorous  and 

atively  few  in  number.     Later,  during        sibilant  rales  are  very  abundant.    The 
the    second   or  third  day,  these  give        following   day  either  the  respiratory 
place  to  large  and  small  mucous  rales.         murmur  may  be  normal,  or  an  abun- 
dance of  moist  rales,  due  to  the  atten- 
dant bronchitis,  may  be  present. 

Simple  bronchitis  can  be  easily  distinguished  from  well-marked  cases 
of  emphysema,  but  the  latter  disease  is  usually  associated  with  more  or 
less  inflammation  of  the  bronchial  mucous  membrane.  The  distinctive 
points  in  the  two  diseases  are  as  follows : 

Broxchiti-  Emphysema. 

Inspection. 

Form  and  movements  of  the  chest  Prominence  of  the  upper  portions  of 

natural.  the    chest,   barrel-shaped,   with   more 

or  less  constant  expansion  of  the  su- 
perior ribs,  which  are  elevated  in  in- 
spiration as  though  united  in  a  single 
bone.  Depression  of  the  soft  parts  in 
inspiration,  notably  above  the  clavicles 
and  sternum  and  at  the  lower  portions 
of  the  chest. 


ACUTE  BRONCHITIS.  93 

Bronchitis.  Emphysema, 

Percussion. 

Resonance  normal.    In  exceptional  Vesiculo-tympanitic  resonance  more 

instances     slight   dulness,     especially        or  less  marked, 
over  the  lower  part  of  the  chest. 

Auscultation. 
Vesicular  murmur  sometimes  incom-  The  respiratory  sounds  feeble,  but 

plete.  The  expiratory  murmur  not  expiration  greatly  prolonged.  Com- 
prolonged.     Numerous  rales.  paratively  few  rales. 

Bronchitis  is  distinguished  from  pulmonary  hemorrhage  by  the  his- 
tory and  character  of  the  sputa.  The  physical  signs  are  identical,  ex- 
cept the  absence  in  the  latter  of  dry  rales.,  with  the  harsh  quality  of 
respiration  often  found  in  bronchitis. 

Before  the  days  of  auscultation  and  percussion,  chronic  bronchitis 
was  often  mistaken  f  or  phthisis,  but  at  present  the  physical  signs  render 
their  distinction  comparatively  easy.  They  differ  in  the  following  par- 
ticulars : 

Bronchitis.  Phthisis. 

Inspection. 
Form  and  movements  of  the  chest  Very  early  in  the  disease  more  or 

natural.  less  depression  over  the  affected  re- 

gion, with  lessened  expansion. 

Palpation. 
Rhonchial   fremitus,    with    normal  Vocal  fremitus  exaggerated, 

vocal  fremitus. 

Percussion. 
Resonance  normal.  More  or  less  dulness  over  the  affected 

regions. 

Auscultation. 
Rales  found  in  this  disease  are  equally  Rales  and  other  signs  of  consolida- 

diffused  over  both  lungs.  Expiratory  tion  localized,  limited  to  the  portion 
murmur  not  notably  prolonged.  Res-  of  lung  affected.  Broncho-vesicular 
onance  natural.  inspiration  and  exaggerated  vocal  res- 

onance. 

Microscopic. 
No  bacilli  of  tuberculosis  in  the  spu-  Tubercle  bacilli ;  elastic  fibres, 

turn,  nor  elastic  fibres. 

Prognosis. — Acute  bronchitis  generally  terminates  in  recovery  with- 
in a  few  days  or  at  most  two  weeks,  even  without  treatment.  It  is  sel- 
dom serious  except  in  infants  and  the  aged,  or  very  feeble  patients  in 
whom  it  not  infrequently  develops  into  the  capillary  form.  In  the  dia- 
thetic or  cachectic,  oft-repeated  acute  attacks  are  apt  to  occur  and  lead 
to  chronic  bronchitis.     This  latter  form,  though  in  itself  rarely  fatal,  is 


94  PULMONARY  DISEASES. 

not  easily  curable  and  gradually  tends  to  the  development  of  asthma  or 
more  serious  conditions,  such  as  emphysema,  bronchiectasis,  atelectasis, 
and  fibroid  phthisis.  Emphysema  is  peculiarly  liable  to  result  from 
dry  catarrh  of  the  bronchi. 

Treatment. — In  many  cases  the  acute  disease  may  be  aborted,  if 
seen  early,'by  a  hot  stimulating  draught  at  bed-time  and  the  application 
of  sinapisms  over  the  chest;  or  a  ten-grain  dose  of  Dover's  powder, 
quinine,  or  phenacetine,  eight  grains  of  antipyrine,  five  of  acetanilide, 
or  a  moderately  full  dose  of  jaborandi  or  its  active  principle  pilocarpine. 
Failing  in  this,  we  may  use  with  advantage  small  doses  of  opium  or  of 
aconite;  or  troches  of  morphine,  antimony,  and  ipecac  compound  (Form. 
32) ;  or  a  combination  of  morphine,  ammonium  chloride,  and  tartar  emet- 
ic (Form.  1);  or  troches  of  compound  licorice  mixture  (Form.  34)  until 
the  expectoration  becomes  free.  Subsequently  for  cough  it  will  be 
found  beneficial  to  administer  extract  of  cannabis  indica  (A Hen's)  gr.  ^ 
to  \,  extract  of  hyoseyamus  (alcoholic)  gr.  h  to  i.,  extract  of  nux  vomica 
gr.  |  to  ^,  quinine  hydrobromate  gr.  i.  to  ij.,  monobromated  camphor  gr.  ij. 
to  gr.  iij.  every  four  to  six  hours.  Ammonium  carbonate  with  small  doses 
of  morphine  (Form.  5)  is  also  useful.  If  the  cough  is  not  very  trouble- 
some, we  may  give  potassium  chlorate,  3  ss.  to  3  i.  daily  in  divided  doses. 
Tonics  may  be  required  until  resolution  is  complete. 

The  subacute  form  of  the  disease  is  treated  in  essentially  the  same 
manner. 

Chronic  bronchitis  is  often  dependent  upon  some  constitutional  dis- 
ease or  diathesis  which  should  receive  our  first  attention,  together  with 
improvement  as  far  as  possible  of  the  hygienic  surroundings,  and  the 
correction  of  vicious  habits.  If  it  is  due  to  the  dartrous  diathesis,  ar- 
senious  acid,  gr.  4J(1  to  gr.  ^   three  times  a  day,  is  especially  indicated. 

For  the  rheumatic  or  gouty  diathesis,  one  or  more  of  the  following 
remedies  may  be  given  from  three  to  five  times  a  day:  Potassium  acetate 
gr.  xv.,  resin  of  guaiac  gr.  x.  to  xv.,  or  its  ammoniated  tincture  3  ss.  to 
3  i.,  potassium  iodide  gr.  v.  to  x.,  tincture  of  colchicum  ttix.  to  xx. 
Even  in  these  chronic  conditions,  salicylic  acid  or  sodium  salicylate  is 
sometimes  very  beneficial,  as  also  salol.  In  some  instances  undoubted 
benefit  is  derived  from  phytolacca.  In  a  large  percentage  of  these  cases 
the  digestive  organs  will  be  found  at  fault,  and  the  greatest  good  will 
follow  a  judicious  use  of  laxatives  and  the  administration  of  remedies 
which  will  correct  gastric  and  intestinal  indigestion. 

Many  patients  having  the  gouty  or  rheumatic  diathesis  are  subject  to 
eructations  of  gas  or  sensations  of  weight  and  fulness  of  the  stomach 
shortly  after  eating,  or  to  flatulence.  The  indications  here  are  to  hasten 
digestion  and  prevent  decomposition  of  food.  To  this  end  I  have  often 
found  of  great  service  a  capsule  containing  the  following,  given  before 
meals  and  at  bed-time  or  before  and  after  meals  according  to  the  sever- 
ity of  the  case: 


CAPILLARY  BRONCHITIS.  95 


3  Capsici, 


ST.  SS. 


gr.  h 
gr-  ij. 

gr.  iij- 


Hy drastirue  hydrochlorat. , 
Extract,  nucis  vomica?, 
Acid,  salicj'lici,    . 
Papain  (Carica  papaya),     . 
M.  Inclose  in  capsule. 

The  hydrochlorate  of  hydrastine  here  used  is  the  article  commonly  known 
as  such  in  medicine,  but  in  pharmacy  and  chemistry  it  is  more  correctly  termed 
hydrochlorate  of  berberine. 

When  the  digestive  trouble  is  mainly  gastric,  the  salicylic  acid  is 
preferable  to  prevent  decomposition ;  but  if  flatulence  is  a  prominent 
symptom,  salol  will  be  found  efficacious.  Of  the  digestive  agents,  pa- 
paine  is  to  me  most  satisfactory,  but  sometimes  pepsin,  pancreatin,  and 
ingluvin  are  useful. 

If  the  affection  originates  in  syphilis,  potassium  iodide  in  full  doses, 
with  mercury  bichloride,  will  have  the  best  effect. 

When  the  disease  is  of  simple  catarrhal  origin,  potassium  chlorate, 
3  i.  daily  in  divided  doses,  is  one  of  the  best  internal  remedies.  Prep- 
arations of  squill,  senega,  yerba  santa,  and  eucalyptus  are  sometimes 
beneficial.  Vegetable  and  mineral  tonics,  cod-liver  oil,  and  preparations 
of  malt  are  indicated  for  debility. 

Persistent  counter-irritation  sometimes  aids  greatly  in  promoting  a 
cure. 

Locally,  inhalations  similar  to  those  recommended  for  diseases  of  the 
throat  (Form.  62,  63,  67,  69,  72,  and  73)  are  beneficial,  and  in  some 
instances,  particularly  where  there  is  free  secretion,  great  relief  is  ob- 
tained from  the  inhalation  of  thymol  gr.  ss.  to  i.  to  5  i.  of  liquid  albolene. 

Cough  may  be  relieved  by  small  doses  of  morphine  and  ammonium 
carbonate  (Form.  5),  by  troches  of  morphine,  or  cannabis  indica  and 
terpin  hydrate  compound  (Form.  33),  and  often  by  sedative  inhalations 
(Form.  53-59).  For  dyspnoea,  the  nitrites  in  some  form  are  specially 
beneficial.  Great  care  should  be  taken  on  the  part  of  the  patient  to 
avoid  damp  feet,  exposure  to  night  air,  cold  drafts,  overheated  atmos- 
phere, and  the  inhalation  of  irritating  substances. 

When  practicable,  change  of  climate  is  often  highly  beneficial.  When 
the  bronchial  secretions  are  profuse,  the  patient  is  likely  to  obtain  most 
benefit  in  a  higher  altitude  with  dry  atmosphere;  if  the  secretions  are 
scanty  or  tenacious,  a  moist  climate  with  an  equable  temperature  like 
that  found  at  the  seashore  in  Southern  California  or  along  the  coast  of 
the  Gulf  of  Mexico  is  more  salutary. 

CAPILLARY    BRONCHITIS. 

Capillary  bronchitis  consists  of  an  acute  inflammation  of  the  mucous 
membrane  lining  the  capillary  bronchial  tubes.  It  usually  results  from 
extension  of  inflammation  affecting  the  larger  bronchi,  and  it  affects 
both  lungs  at  once. 

Anatomical  axd  Pathological  Characteristics. — Evidence  ren- 


96  PULMONARY  DISEASES. 

dered  by  autopsies  indicates  that  capillary  bronchitis  without  accom- 
panying inflammation  of  the  air  vesicles  is  very  rare.  In  most  cases  the 
mucous  membrane  of  the  larger  tubes  is  first  involved,  and  during  the 
progress  of  the  disease  the  small  tubes  become  more  or  less  blocked  with 
secretion ;  this  has  a  valve-like  action,  which  prevents  air  from  entering 
some  of  the  alveoli  during  inspiration,  but  allows  it  to  escape  in  expira- 
tion, so  that  these  air  cells  collapse,  and  as  a  result  the  cells  in  adjoining 
lobules  are  correspondingly  distended.  The  lung  consequently  has  an  ir- 
regular mottled  appearance,  from  interspersed  sunken  atelectatic  patches 
and  elevated  distended  air  sacs. 

Etiology. — The  etiology  of  capillary  bronchitis  is  that  of  acute 
bronchitis,  it  usually  resulting,  in  children  and  the  aged,  from  extension 
of  inflammation  from  the  larger  tubes. 

Symptomatology. — The  principal  symptoms,  in  addition  to  those 
found  in  acute  bronchitis,  are  severe  dyspnoea  with  lividity  of  the  sur- 
face and  great  prostration,  following  marked  febrile  reaction  and  accom- 
panied by  rapid  resjriration  and  a  weak  pulse. 

The  principal  signs  are:  absence  of  dulness,  occasionally  exagger- 
ated resonance  and  sibilant  or  subcrepitant  rales  on  both  sides  (Fig. 
17). 

By  inspection,  respiratory  movements  are  found  to  be  rapid,  and  the 
countenance  shows  the  effects  of  imperfect  aeration  of  the  blood  as  the 
disease  advances. 

Palpation  occasionally  yields  a  rhonchial  fremitus,  due  to  disease  in 
the  larger  bronchial  tubes. 

Percussion  obtains  a  resonance  normal  or  slightly  exaggerated  over 
the  lower  portions  of  the  chest.  This  exaggeration  is  due  to  emphysema 
of  a  portion  of  the  air  vesicles,  which  results  from  complete  occlusion  of 
some  of  the  smaller  tubes,  with  collapse  of  their  terminal  vesicles,  and 
consequent  dilatation  of  the  surrounding  air  cells. 

Auscultation  usually  furnishes  signs  of  general  bronchitis,  and  in 
addition  to  these,  early  in  the  course  of  the  affection,  sibilant  rales  are 
found  in  great  abundance,  which  a  little  later  are  replaced  by  subcrepi- 
tant rales.  These  subcrepitant  rales,  when  numerous  and  attended  by 
the  symptoms  already  mentioned,  may  be  taken  as  a  positive  sign  of 
capillary  bronchitis,  but  a  few  are  frequently  heard  over  the  lower  ])or- 
tion  of  the  chest,  simply  from  gravitation  of  fluids,  or  of  the  products  of 
inflammation  from  the  larger  bronchial  tubes. 

Occasionally  a  few  subcrepitant  rales  are  heard,  near  the  borders  of  the  lung, 
even  in  health. 

Subcrepitant  rales,  when  confined  to  the  apex  or  to  the  base  of  one 
lung,  usually  indicate  that  the  capillary  bronchitis  producing  them  is 
either  of  tuberculous  or  of  emphysematous  origin. 

Diagnosis. — Capillary  bronchitis  is  attended  by  signs  similar   to 


CAPILLARY  BRONCHITIS.  97 

some  of  those  found  in  asthma,  pneumonia,  or  pulmonary  oedema.     This 
disease  may  be  distinguished  from  asthma  by  the  history. 

Capillary  bronchitis  cannot  be  mistaken  for  the  first  or  second  stage 
of  lobar  'pneumonia  if  we  bear  in  mind  that  neither  of  these  stages  causes 
many  sibilant  or  subcrepitant  rales,  which  are  abundant  in  bronchitis, 
and  that  both  stages  are  attended  by  marked  dulness,  while  in  bronchitis 
resonance  is  either  unaltered  or  exaggerated.  From  the  third  stage  of 
lobar  pneumonia  this  disease  is  distinguished  by  the  signs  obtained  by 
palpation,  percussion,  and  auscultation,  as  follows  : 

Capillary  bronchitis.  Lobar  pneumonia. 

Palpation. 
No  increase  in  the  vocal  fremitus.  Vocal  fremitus  increased. 

Percussion. 
No  dulness;  occasionally  exaggerated  More  or  less  dulness. 

resonance. 

Auscultation. 

Subcrepitant  rales  over  both  lungs  ;  Subcrepitant  rales  confined  to  one 

these  rales  are  of  low  pitch.  side,  over  the  affected  lung  ;  these  rales 

are  high  in  pitch. 

It  is  difficult  to  distinguish  between  capillary  bronchitis  and  lobular 
pneumonia,  with  which  it  often  coexists;  but  the  diagnosis  may  be 
made  fairly  certain  by  attention  to  the  following  points: 

Capillary  bronchitis.  Lobular  pneumonia. 

Symptoms. 
Moderate  fever.     Moderately  accel-  High  fever.     Very  rapid  respiration, 

erated  respiration. 

Percussion. 

No  dulness,  but  possibly  exaggerated  Limited  unchanging  spots  of  dulness 

resonance.  may  sometimes  be  detected,  though,  as 

the  disease  usually  occurs  in  children, 
in  whom  dulness  is  difficult  to  detect, 
this  sign  is  liable  to  escape  observation. 

Auscultation. 
Multitudes  of  fine  dry  or  moist  rales  The  rales  are  limited  in  area  unless 

over  every  part  of  the  chest.  the  two  diseases  coexist.     Bronchial 

breathing  can  occasionally  be  detected. 

Capillary  bronchitis  is  distinguished  from  pulmonary  oedema  by  the 
following  symptoms  and  signs: 

Capillary  bronchitis.  Pulmonary  cedema. 

History. 
Febrile  symptoms.  No  febrile  symptoms. 

Usually  shpws  an  antecedent  acute  This  affection  usually  follows  some 

bronchitis  several  days  in  duration.  protracted  disease,  as  typhoid  fever,  or 

affections  of  the  heart  or  kidnevs. 


98  PULMONARY  DISEASES. 

Capillary  bronchitis.  Pulmonary  cedema. 

Percussion. 

Resonance  normal  or  exaggerated.  Dulness  over  the  lower  part  of  both 

lungs. 

Auscultation. 

Usually  numerous  rales  in  the  larger  Signs  of  general   bronchitis  f  re- 

tubes,  quently  absent. 

Capillary  bronchitis  is  distinguished  from  phthisis  by  the  history  of 
the  case,  and  by  the  fact  that  the  subcrepitant  rales  of  the  latter  affec- 
tion are  limited  to  a  smaller  portion  of  the  chest,  which  is  usually  over 
the  apex  of  one  lung. 

Prognosis. — This  disease  in  severe  cases  may  prove  fatal  within 
eighteen  hours,  but  usually  it  extends  over  four  or  five  days.  The  rate 
of  mortality,  though  differently  estimated,  is  extremely  high,  especially 
for  the  aged  and  for  infants  under  one  year.  When  following  whooping- 
cough  or  measles,  or  complicating  any  serious  organic  trouble,  or  occur- 
ring in  delicate  children,  the  prognosis  is  also  unfavorable.  Convales- 
cence in  any  event  is  apt  to  be  tedious  and  recovery  incomplete, 
attended  by  more  or  less  permanent  crippling  of  one  or  both  lungs  by 
collapse  of  the  alveoli  and  hyperplasia  of  the  connective  tissue.  The 
prognosis  should  therefore  always  be  guarded. 

Death  generally  results  from  asphyxia,  and  its  approach  is  indicated 
by  signs  of  extensive  involvement  of  the  lungs,  difficult  expectoration, 
cessation  of  cough,  dyspnoea,  cyanosis,  or  the  symptoms  of  collapse.  A 
temperature  of  105°  F.  or  more,  if  long  continued,  is  very  unfavorable. 

Treatment. — Opiates  should  not  be  used  in  this  disease  excepting 
in  very  small  doses.  Early  in  the  disease,  ammonium  chloride  with 
syrup  of  ipecac  will  be  useful;  but  after  two  or  three  days,  more  benefit 
will  be  derived  from  ammonium  carbonate.  Inhalations  of  steam,  or 
steam  impregnated  with  sedative  remedies,  have  a  soothing  effect  on  the 
inflamed  bronchi  (Form.  53-59).  Ammonium  iodide  in  small  and  often 
repeated  doses  is  sometimes  a  most  efficient  remedy.  Strychnine,  gr. 
■jV  t°  ^5-5  is  a  valuable  remedy  in  this  affection,  as  soon  as  symptoms  of 
exhaustion  supervene.  Alcoholics  should  be  used  to  sustain  the  strength, 
if  the  ammonium  carbonate  does  not  seem  sufficient.  Cough  and  any 
spasmodic  tendency  may  be  relieved  by  camphor  or  the  bromides. 

In  children  it  is  necessary  to  watch  carefully  the  secretion  of  urine 
in  order  to  avoid  a  frequent  cause  of  dyspnoea;  digitalis  internally  and 
cataplasms  over  the  kidneys  are  usually  effective  in  promoting  free  renal 
secretion  (Simon:  Medical  Neivs,  January,  1890). 

The  most  efficient  remedies  are  ammonium  carbonate  and  strychnine, 
with  large  jacket  poultices  kept  constantly  warm  and  moist  and  cover- 
ing the  whole  chest.     The  diet  must  be  nourishing. 


PLASTIC  BRONCHITIS.  99 

PLASTIC    BRONCHITIS. 

Synonyms. — Pseudo-membranous,  croupous,  exudative,  or  fibrinous 
bronchitis. 

Bronchitis  is  sometimes  complicated  by  exudation  of  fibrinous  matter, 
with  the  formation  of  false  membrane  or  plastic  casts  in  the  smaller  air 
tubes  and  their  ramifications  and  occasionally  in  the  larger  bronchi. 
This  affection  may  be  acute  or  chronic. 

Anatomical  and  Pathological  Characteeistics. — The  affection 
is  generally  chronic,  and  usually  involves  the  smaller  bronchi  only.  It 
is  most  frequently  circumscribed,  but  may  be  diffuse  in  acute  cases,  and 
is  marked  by  exudation  from  the  surface  of  the  bronchial  mucous  mem- 
brane of  fibrinous  material,  forming  casts,  which  have  a  laminated 
structure,  the  layers  being  separable  when  dry.  This  substance  is  com- 
posed of  coagulated  albumin  (soluble  in  alkali),  containing  leucocytes 
and  fat  globules,  sometimes  octahedral  crystals,  a  few  red  corpuscles, 
and  epithelial  cells.  It  is  firm  and  of  a  white,  gray,  or  yellow  color, 
occasionally  specked  with  blood.  Seemingly  the  mucous  membrane 
beneath  it  is  not  seriously  implicated,  but  may  be  either  congested 
or  pale. 

Etiology. — The  ultimate  cause  of  plastic  bronchitis  is  not  as  yet 
known.  Though  poverty,  exposure,  and  feeble  health  are  mentioned  as 
favoring  its  occurrence,  excepting  diphtheria,  no  particular  diseases  or 
conditions  have  been  ascertained  to  bear  special  causal  relation  to  it. 

Authorities  differ  as  to  its  comparative  frequency  relative  to  age  and 
sex.  According  to  Peacock  it  more  often  affects  men  (Transactions  of 
the  Pathological  Society,  Vol.  V,  London). 

Symptomatology. — The  prominent  symptoms  are:  hacking  cough 
with  scanty  expectoration,  followed,  after  a  varying  interval  of  from  a 
few  hours  to  several  days,  by  a  sense  of  constriction  in  the  chest,  and 
dyspnoea  which  may  be  very  severe.  The  cough  gradually  increases  in 
severity,  the  expectoration  becomes  more  abundant  and  perhaps  tinged 
with  blood  or  accompanied  with  profuse  haemoptysis,  and  finally  small 
fragments  of  the  fibrinous  matter  are  brought  up  or,  after  severe  parox- 
ysms of  cough,  complete  casts  of  the  bronchi.  These  casts  may  be  solid  or 
hollow,  varying  in  diameter  up  to  half  an  inch  and  in  length  from  a 
fraction  of  an  inch  to  six  inches,  the  counterpart  of  the  branching  bron- 
chial tree. 

The  physical  signs  are  those  of  ordinary  bronchitis,  superadded  to 
which  are  the  signs  due  to  partial  or  complete  obstruction  of  some  of 
the  bronchial  tubes,  viz.,  weakness  or  absence  of  the  respiratory  mur- 
mur, with  dulness  where  portions  of  the  lung  are  collapsed.  These 
signs  may  lead  to  an  erroneous  diagnosis  of  pleurisy  or  of  pneumonia. 
From  the  former,  plastic  bronchitis  is  distinguished  by  absence  of  catch- 
ing respiration,  pains,  and  friction  sounds ;  by  the  speedy  occurrence  of 


100  PULMONARY  DISEASES. 

dulness  with  loss  of  the  respiratory  murmur  and  vocal  signs,  and  by  the 
presence  of  signs  of  bronchitis  in  other  parts  of  the  chest. 

We  distinguish  it  from  pneumonia  by  the  absence  of  bronchial 
breathing,  and,  when  collapse  of  the  lung  occurs,  by  the  sudden  acces- 
sion of  the  signs  of  consolidation.  The  differentiation  from  ordinary 
bronchitis  rests  entirely  upon  the  expectoration  of  fibrinous  casts. 

Prognosis. — The  mortality  in  the  acute  form  is  about  fifty  per  cent, 
death  occurring  in  from  five  to  fifteen  days.  Though  complete  recovery 
from  chronic  plastic  bronchitis  is  rare,  death  simply  from  this  form  is 
equally  so. 

Treatment. — During  the  acute  attack  or  during  exacerbations  of 
the  chronic  form  of  plastic  bronchitis,  the  treatment  should  be  essen- 
tially the  same  as  that  for  membranous  croup. 

Stirling  recommends  inhalations  of  lime  water,  strong  or  dilute  or 
combined  with  a  two  to  five  per  cent  of  sodium  bicarbonate,  in  which 
the  casts  are  soluble.  Turpentine,  cubebs,  and  copaiba  tend  to  render 
them  more  plastic. 

At  other  times,  potassium  iodide  will  afford  some  relief.  The  gen- 
eral health  must  be  maintained  and  all  causes  of  cold  avoided. 

A  warm  climate  is  advisable,  and  if  possible  a  sea  voyage. 

DILATATION   OF   THE  BRONCHIAL  TUBES. 

Synonyms. — Bronchiectasis  or  bronchicatasis,  knife-grinder's  rot, 
filer's  phthisis,  cirrhosis  of  the  lungs.  It  is  sometimes  termed  fibroid 
phthisis. 

Anatomical  and  Pathological  Characteristics. — Dilatation  of 
the  bronchi  is  usually  associated  with  fibrous  induration  of  the  lungs  or 
with  vesicular  emphysema.  It  is  generally  found  in  the  smaller  tubes 
over  the  middle  or  the  lower  portion  of  the  lung,  more  frequently  on 
the  right  than  on  the  left  side. 

The  affection  may  be  general  or  partial,  single  or  multiple,  and  may 
be  fusiform,  cylindrical,  or  saccular.  The  bronchus  so  affected  may 
continue  of  normal  calibre  on  each  side  of  the  enlargement;  it  may  be 
narrowed  or  obstructed  on  either  the  distal  or  the  proximal  side;  or 
obliterated  on  both.  The  walls  of  such  a  cavity  frequently  show  atrophy 
of  the  mucous  membrane,  with  its  secreting  glands,  or  they  may  present 
a  surface  more  or  less  irregular  and  granular.  The  submucous  elastic 
tissue  is  hypertrophied,  the  muscular  coat  normal,  atrophied,  or  its  fibres 
widely  separated.  The  cartilages  may  be  thickened  or  may  have  par- 
tially disappeared,  but  the  connective-tissue  elements  are  greatly  hyper- 
trophied, and  the  adjacent  interstitial  lung  tissue  is  involved  in  the 
same  process. 

Etiology. — Bronchiectasis  may  arise  from  increased  pressure  within 
the  bronchi  or  from  weakening  changes  in  the  walls  or  surrounding  lung 


DILATATION  OF  THE  BRONCHIAL   TUBES.  101 

tissue.  It  may  be  the  result  of  alveolar  collapse  or  atelectasis  or  stenosis 
of  the  bronchi  from  any  cause,  but  chiefly  from  chronic  bronchitis,  also 
from  phthisis  and  occasionally  from  old  pleuritic  adhesions. 

Symptomatology. — Patients  affected  with  bronchiectasis  often  have 
the  general  appearance  and  symptoms  of  phthisical  subjects.  The  prin- 
cipal distinctive  symptom  is  the  expectoration  of  opaque,  purulent,  and 
extremely  offensive  sputum,  which  is  very  abundant,  measuring  some- 
times three  pints  in  twenty-four  hours. 

The  principal  signs  are :  more  or  less  dulness,  and  a  harsh  inspiratory 
murmur  with  numerous  rales,  all  of  which  signs  may  rapidly  change. 

Inspection  shows  imperfect  expansion  of  the  chest,  prolonged,  labored 
expiration,  with  more  or  less  fixity  of  the  chest  walls,  and  depression  of 
the  intercostal  spaces. 

The  signs  obtained  by  palpation,  percussion,  and  auscultation  vary 
greatly  at  different  times,  according  to  the  amount  of  fluid  in  the  tubes 
or  cavities.  This  variation  in  the  signs  is  of  itself  almost  diagnostic  of 
the  disease. 

By  palpation,  the  rhonchial  fremitus  may  or  may  not  be  obtained. 
The  vocal  fremitus  may  be  normal,  but  it  is  sometimes  increased,  at 
other  times  diminished. 

By  percussion,  some  dulness  is  usually  obtained  over  the  affected 
lung.  This  is  sometimes  removed  by  free  expectoration,  and  may  then 
be  followed  by  vesiculo-tympanitic  or  perhaps  a  cracked-pot  resonance. 
Dulness  is  apt  to  be  located  at  the  middle  or  lower  part  of  the  lung,  and 
is  most  common  on  the  right  side.  Light  percussion  usually  elicits  dul- 
ness, when  a  more  forcible  stroke  would  produce  a  somewhat  tympanitic 
sound. 

On  auscultation,  we  sometimes  find  the  respiratory  murmur  sup- 
pressed over  a  considerable  portion  of  the  lung,  while  round  about  it  the 
sounds  may  be  harsh  and  loud.  A  little  later,  free  expectoration  having 
emptied  the  bronchial  tubes  and  cavities  communicating  with  them, 
respiration  may  become  broncho-vesicular  and  intense,  where  at  first  it 
could  not  be  heard.  The  respiratory  murmur  is  often  associated  with 
numerous  adventitious  sounds  of  every  variety  from  the  dry,  sibilant 
rale  to  gurgles. 

Vocal  resonance  is  subject  to  similar  changes,  and  from  the  same 
causes. 

Diagnosis. — Bronchiectasis  is  most  likely  to  be  mistaken  iov  phthisis, 
from  which  it  can  only  be  distinguished  by  attention  to  the  expectora- 
tion, and  to  the  mutability  of  the  physical  signs.  The  distinctive 
features  between  the  two  are  as  follows : 

Bronchiectasis.  Phthisis. 

Palpation. 
Fremitus  changeable.  Exaggerated  vocal  fremitus  not  uni- 

versal, but  when  present  usually  con- 
stant. 


102  PULMONARY  DISEASES. 

Bronchiectasis.  Phthisis. 

Percussion. 
Dulness,  or  vesiculotympanitic  l'eso-  More  or  less  dulness,  which  remains 

nance,  often  changing  from  one  to  the        constant, 
other  during  the  examination. 

Auscultation. 
The  signs  are  usually  found  over  the  The   signs  for  several   months  are 

lower  or  middle  portions  of  one  or  both  usually  confined  to  the  upper  portion 
lungs,  and  change  rapidly  as  the  re-  of  one  lung.  They  are  not  materially 
suit  of  deep  inspiration  or  cough.  altered  by  cough  or  by  deep  inspira- 

tion. They  are  confined  to  a  more 
limited  space  than  the  signs  of  dilata- 
tion of  the  bronchi. 

Prognosis. — Bronchiectasis  runs  a  chronic  course,  and,  though  not 
fatal  in  itself,  is  inductive  of  other  pulmonary  disease,  especially  predis- 
posing to  putrid  bronchitis,  and  gangrene  or  abscess  of  the  lung.  It  is  in- 
curable and,  being  secondary  to  chronic  bronchitis,  old  pleuritic  adhe- 
sions and  thickening,  atelectasis  or  fibroid  phthisis,  its  prognosis  depends 
upon  that  of  the  associated  disease. 

Hectic,  rapid  pulse  and  progressive  emaciation  with  night  sweats  are 
unfavorable  symptoms,  but  these  symptoms,  attended  by  most  abundant 
fetid  expectoration  and  great  asthenia,  giving  the  appearance  of  the  last 
stage  of  consumption,  sometimes  disappear  in  a  partial  recovery,  so  that 
the  patient  lives  in  fairly  good  health  for  a  year  or  two. 

Treatment. — In  bronchiectasis,  cod-liver  oil,  calcium  chloride,  and 
vegetable  tonics  are  generally  demanded.  Some  of  the  preparations  of 
eucalyptus  globulus  or  grindelia  robusta  are  occasionally  beneficial,  as 
are  also  copaiba,  turpentine,  senega,  and  squills.  Potassium  or  ammo- 
nium iodide  and  arsenic  are  also  useful.  Inhalations  of  turpentine, 
camphor,  iodine,  and  carbolic  acid  are  frequently  useful  in  checking  or 
altering  the  secretions  (Form.  66,  67,  68,  70,  71,  73).  Counter-irritation 
should  be  tried. 

ASTHMA. 

Asthma  is  a  spasmodic  affection  of  the  respiratory  apparatus,  chiefly 
characterized  by  paroxysmal  attacks  of  dyspnoea. 

Anatomical  and  Pathological  Characteristics. — There  are  no 
recognized  morbid  changes  peculiar  to  asthma.  It  is  a  functional  dis- 
order or  neurosis  dependent  upon  some  physical  condition  not  yet  thor- 
oughly understood.  Many  hypotheses  have  been  advanced  to  explain 
the  mechanism  and  cause  of  asthmatic  dyspnoea. 

Though  none  of  them  have  become  entirely  adequate  theories,  the 
bronchial  spasm  hypothesis  is  the  one  most  commonly  accepted.  Ac- 
cording to  this,  the  dyspnoea  is  due  to  spasm  of  the  annular  muscular 
fibres  of  the  bronchi  which  narrows  their  calibre  and  obstructs  the  pas- 


ASTHMA.  103 

sage  of  air.  That  bronchial  constriction  occurs  in  asthma  is  proved  by 
the  constant  presence  of  sibilant  rales. 

Some,  with  Wintrich,  consider  spasm  of  the  diaphragm  as  accounta- 
ble for  the  difficult  breathing. 

Weber  and  others  hold  that  it  is  due  to  vasomotor  relaxation  pro- 
ducing congestion  and  tumefaction  of  the  bronchial  mucous  membrane. 
Crystals  and  spirals  found  in  the  sputum  by  Leyden  and  Curschmann, 
and  supposed  to  be  causative,  as  irritants  to  the  bronchial  mucous  mem- 
brane, have  been  ascertained  to  be  present  not  alone  in  asthma,  but  also 
in  many  pulmonary  disorders. 

Etiology. — Although  the  ultimate  cause  of  asthma  is  unknown, 
certain  predisposing  conditions  are  recognized;  according  to  Salter, 
heredity  is  to  be  traced  in  forty  per  cent  of  all  cases;  others  claim 
a  smaller  percentage  (Lazarus  in  Deutsche  medicinische  Zeitimg, 
1887). 

The  neurotic  temperament  seems  to  favor  it,  particularly  if  coupled 
with  plethora ;  also  the  rheumatic  and  gouty  diathesis.  It  is  common 
to  all  ages.  Its  victims  are  most  often  males,  those  preferably  of  the 
upper  class.  Soltmann  thinks  it  especially  common  among  the  Hebrews 
(Shattuck:  Cyclopedia  of  Diseases  of  Children,  Keating).  Asthmatics 
usually  suffer  most  in  winter,  and  the  attacks  occur  generally  at  night. 
Its  exciting  causes  may  be  considered  as  those  acting  directly  as  irritants 
to  the  terminal  fibres  of  the  vagus  or  sympathetic  in  the  bronchial 
mucous  membrane,  and  those  acting  reflexly  from  a  greater  or  less  dis- 
tance. Bronchitis  is  the  most  frequent  exciting  cause  of  asthma.  An 
asthmatic  attack  may  arise  from  inhalation  of  dust,  smoke,  fog,  and 
other  vapors,  pungent  fumes,  odors  from  certain  plants,  pollen,  and 
emanations  from  animals.  Indeed,  the  list  of  substances  capable  of 
exciting  an  asthmatic  paroxysm  is  long. 

Different  patients  are  affected  each  in  his  own  peculiar  way,  one 
by  the  presence  in  the  atmosphere  of  one  substance  or  condition,  another 
by  one  totally  different.  The  diseases  and  conditions  which  by  reflex 
impression  upon  the  bronchial  nervous  mechanism  excite  the  asthmatic 
paroxysm  are  also  very  numerous  and  varied.  Not  infrequent  causes 
are  found  in  irritation  of  the  upper  air  passages  by  impalpable  particles 
diffused  in  the  atmosphere  or  by  such  deformities  as  septal  deflection, 
exostoses,  nasal  polypi,  and  hypertrophy  of  the  tonsils. 

Asthma  has  been  attributed  to  the  pressure  from  a  hypertrophied 
thyroid,  an  aneurism  or  other  tumors,  or  from  enlarged  bronchial  glands. 
It  is  frequently  due  to  some  disorder  of  the  alimentary  tract,  such  as  gas- 
tric indigestion  or  neurosis,  duodenal  catarrh,  hepatic  torpor,  constipation, 
intestinal  worms,  or  hemorrhoids.  It  may  be  due  to  abdominal  tumors 
or  derangements  of  the  genito-urinary  system,  as  for  example  calculi, 
prostatic  enlargement,  enuresis,  spermatorrhoea,  sexual  abuse,  and,  in 
women,  ovarian,  uterine,  and  vaginal  disease.     Diseases  of  the  heart,  of 


104  PULMONARY  DISEASES. 

the  kidney,  or  of  the  brain  may  cause  asthma,  as  may  also  certain  skin 
diseases — eczema,  urticaria,  and  herpes,  for  example.  Poulet  describes  an 
epileptiform  variety  of  asthma  {Journal  de  Medecine  de  Paris,  1889).  It 
seems  sometimes  to  occur  from  presence  in  the  blood  of  poison,  such  as 
the  uraemic,  gouty,  rheumatic,  or  malarial  (Robinson,  Medical  News,  1890), 
or  certain  chemicals  presumably  acting  through  the  circulation  upon 
the  respiratory  centres.  But  back  of  all  these  favoring  conditions  and 
exciting  causes  is  something,  as  yet  unknown,  which  is  an  important  if 
not  the  chief  etiological  factor  in  the  production  of  the  disease.  Cases 
occur  in  which  the  most  careful  examination  fails  to  find  any  predispos- 
ing or  exciting  cause. 

Symptomatology. — Asthma  is  characterized  chiefly  by  paroxysms  of 
dyspnoea,  with  stridulous  respiration  and  the  evidences  of  deficient  aera- 
tion of  the  blood.  In  some  instances  an  attack  may  be  foretold  by  sen- 
sations of  mental  depression,  drowsiness,  or  irritability,  or  their  oppo- 
sites;  or  by  hyperesthesia,  headache,  a  sense  of  constriction  of  the 
throat  or  chest  or  frequent  desire  to  gape  or  sneeze.  Some  attacks  begin 
with  coryza,  which  may  develop  into  bronchitis.  Usually  the  onset  is 
sudden;  the  patient  awakes  from  sleep,  wheezing  and  perhaps  gasping 
for  breath,  with  a  sense  of  thoracic  constriction,  and  if  it  be  his  first 
attack  he  fears  imminent  suffocation.  Breathing  becomes  more  labored, 
accompanied  by  venous  turgescence,  congestion  of  the  face  and  neck, 
bulging  and  suffusion  of  the  eyes,  dilatation  of  the  nostrils,  and  profuse 
perspiration.  The  pulse  decreases  in  strength  with  the  severity  and 
duration  of  the  paroxysm.  The  paroxysms  usually  last  from  two  to 
four  hours,  but  the  attach  sometimes  terminates  in  a  few  minutes.  It 
may  occasionally  continue  for  weeks.  Recurrence  of  the  affection  re- 
sults in  some  patients  only  from  certain  exciting  causes,  in  others  more 
or  less  periodically — daily,  weekly,  monthly,  or  yearly. 

Diurnal  attacks  are  rare.  Frequently  the  paroxysm  terminates  in  a 
mild  bronchitis.  Between  attacks  the  condition  of  asthmatic  patients 
varies  in  degree  from  a  condition  of  apparent  health  to  the  state  of 
more  or  less  constant  suffering  from  the  disease  or  its  sequela?. 

The  principal  signs  are  labored  and  wheezing  respiration,  attended 
by  numerous  sonorous  and  sibilant  rales,  which  may  be  heard,  and 
often  felt,  over  the  whole  chest. 

The  patient  is  usually  found  in  the  upright  position.  Respiration  is 
labored,  inspiration  being  short  and  jerking,  and  expiration  prolonged. 
The  dyspnoea  is  chiefly  expiratory.  The  resjriratory  motion  of  the  chest 
is  greatly  diminished.  Severe  cases  show  the  signs  of  deficient  oxygena- 
tion of  the  blood. 

Inspection,  palpation,  mensuration,  and  percussion  yield  no  distinc- 
tive signs.     The  resonance  may  be  normal  or  slightly  exaggerated. 

By  auscultation  we  obtain  jerking  or  cog-wheel  respiration,  with  a 
great  variety  of  sonorous  and  sibilant  rales.     The  respiratory  murmur 


ASTHMA.  105 

is  usually  harsh  and  more  or  less  tubular,  the  vesicular  element  being 
suppressed.     Vocal  resonance  is  normal. 

Diagnosis. — During  a  paroxysm,  asthma  may  be  mistaken  for 
cardiac  dyspnoea,  capillary  bronchitis,  or  spasmodic  laryngeal  affections. 
From  the  first,  it  may  be  distinguished  by  the  history,  by  the  absence  of 
cardiac  signs  and  by  the  presence  of  a  great  number  of  sonorous  and 
sibilant  rales. 

Asthma  differs  from  capillary  bronchitis  in  its  history,  and  in  some 
of  the  signs  obtained  by  inspection  and  auscultation,  as  shown  in  the 
f  ollowing  table : 

Asthma.  Capillary  bronchitis. 

Symptoms. 
A  sudden  attack,  with  usually  a  his-  Dyspnoea  comes  on  gradually,  usu- 

tory  of  former  paroxysms.  Febrile  ally  preceded  by  acute  or  subacute 
symptoms  not  marked.  bronchitis.      Febrile    symptoms    pro- 

nounced. 
Inspection. 
Respiration  labored,  but  not  greatly  Respiration   not  only    labored,   but 

accelerated.  also  rapid. 

Auscultation. 
Sonorous  and  sibilant  rales,  usually  Mucous  rales  likely  to  precede  the 

followed  by  large  and  small  mucous  sibilant  rales,  and  the  sibilant  to  be 
rales.  followed  by  the  subcrepitant. 

Spasmodic  affections  of  the  larynx  are  distinguished  as  follows: 

Asthma.  Spasmodic  laryngeal  affections. 

Dyspnoea,  expiratory.  Dyspnoea  inspiratory. 

Rales.  No  rales. 

No  local  laryngeal  signs.  Laryngeal  signs  sometimes  positive. 

No  change  in  voice.  Voice  altered. 

After  the  paroxysm,  the  signs  of  asthma  are  like  those  of  bronchitis, 
but  they  last  only  a  few  hours. 

Asthmatic  symptoms  often  occur  during  the  progress  of  pulmonary 
emphysema;  but  these  two  diseases  may  be  easily  distinguished  from 
each  other  by  the  history.  In  emphysema,  as  in  cardiac  disease,  dyspnoea 
is  permanent,  and  aggravated  by  exercise ;  while  in  asthma  the  dyspnoea 
usually  comes  on  during  the  hours  of  rest. 

Prognosis. — Asthmatic  paroxysms  are  very  rarely  fatal.  One  at- 
tack predisposes  to  others,  and  the  disease  is  usually  obstinate.  Hope  of 
complete  cure  is  good  in  proportion  to  the  youth  of  the  patient,  absence 
of  organic  disease,  short  duration  of  the  attacks,  infrequence  of  recur- 
rence, immunity  from  distress  during  the  intervals,  and  the  presence  and 
discovery  of  a  removable  cause.  Chronic  asthma  tends  to  the  develop- 
ment of  emphysema,  chronic  bronchitis,  and  dilatation  and  hypertrophy 
of  the  right  cardiac  ventricle. 


106  PULMONARY  DISEASES. 

Treatment. — During  the  paroxysm,  the  most  effectual  internal 
treatment  consists  of  the  administration  of  morphine  and  chloral  (Form. 
2)  repeated  every  half-hour  or  every  hour  until  relief  is  obtained.  This 
may  be  combined  with  half  a  drachm  of  fl.  ext.  of  grindelia  robusta, 
■which  is  sometimes  beneficial.  The  nitrites  in  the  form  of  nitroglycerin 
gr.  T^o,  or  nitrite  of  amyl  ffiij.  to  v.,  repeated  every  twenty  minutes  for 
two  or  three  doses,  or  apomorphine  gr.  -fa  internally  every  two  hours, 
frequently  prove  effective.  Weill  (La  France  Medicale,  March,  1889) 
through  experiments,  confirmed  by  others,  found  that  inhalation  of  car- 
bon dioxide  greatly  relieved  cough  and  dyspnoea  and  cut  the  paroxysm 
short. 

Two  or  three  cups  of  strong  hot  coffee  will  frequently  abort  an 
attack,  if  taken  when  the  first  symptoms  are  noticed.  The  severity  of 
the  paroxysms  may  be  greatly  modified  by  small  doses  of  belladonna, 
hyoscyamus,  or  hyoscyamine  gr.  yl^  to  y^-y  hypodermically;  or  by  po- 
tassium bromide  or  camphor.  Fuming  inhalations  of  arsenious  acid  or 
potassium  nitrite  alone  or  combined  with  other  antispasmodics  such  as 
stramonium,  hyoscyamus,  or  tobacco,  give  speedy  relief  in  some  cases 
(Form.  132-138).  Galvanizing  the  pneumogastric  nerve,  with  the  pos- 
itive pole  beneath  the  mastoid  process,  and  the  negative  pole  on  the 
epigastrium,  will  promptly  relieve  some  cases. 

If  either  bronchitis  or  pneumonia  supervenes,  it  should  receive  treat- 
ment similar  to  that  recommended  when  it  occurs  as  a  primary  disease. 
The  general  treatment  of  asthmatic  patients  should  be  supporting.  Be- 
tween the  paroxysms  an  effort  should  be  made  to  prevent  their  recur- 
rence. The  most  efficacious  remedy  for  this  purpose  is  potassium  iodide, 
but  in  some  cases  ammonium  iodide,  grindelia,  eucalyptus,  arsenious 
acid,  or  resin  of  guaiac  will  be  found  useful. 

In  all  cases  a  complete  history  should  be  obtained  and  a  thorough 
examination  made  to  ascertain,  if  possible,  the  existence  of  any  disorder 
which  might  cause  a  reflex  bronchial  spasm.  Such  disorder  should 
be  corrected;  thus,  it  will  often  be  possible  to  prevent  or  cure  an  attack 
by  attention  to  the  alimentary  canal. 

It  should  be  remembered  that  asthma  may  result  from  the  rheumatic 
or  dartrous  diathesis,  and  that  it  is  often  caused  by  bronchitis  or  emphy- 
sema, as  Avell  as  by  purely  nervous  affections.  The  treatment  must 
therefore  meet  the  conditions  of  each  case. 

If  all  medicines  fail,  a  change  of  climate  should  be  tried.  The  cli- 
mate of  Colorado  is  perhaps  the  most  frequently  beneficial  to  these 
patients,  but  very  slight  changes  may  be  sufficient  to  prevent  a  recur- 
rence of  the  attacks  ;  therefore  "  each  patient  must  be  a  law  unto  him- 
self "  in  this  regard.  By  repeated  trials,  most  cases  will  find  localities 
where  they  will  be  free  from  asthmatic  attacks. 


PULMONARY  EMPHYSEMA.  107 


PULMONARY  EMPHYSEMA. 


Pulmonary  emphysema  is  an  abnormal  inflation  of  the  lung,  due  to 
over-distention  of  its  air  vesicles  or  accumulation  of  air  in  the  tissues 
about  them;  in  the  former  cases  it  is  commonly  termed  vesicular,  in 
the  latter  extra-vesicular  or  interlobular  emphysema. 

Etiologically  it  is  also  called  primary  or  secondary,  compensatory 
and  vicarious. 

Anatomical  and  Pathological  Chaeacteristics. — Post-mortem 
opening  of  the  chest  in  a  well-marked  case  of  general  emphysema  re- 
veals the  lungs  abnormally  pale,  much  distended  so  as  to  meet  or  over- 
lap anteriorly,  their  surfaces  bearing  the  imprint  of  the  ribs,  their  bor- 
ders rounded.  They  do  not  collapse.  The  heart  may  be  displaced  down- 
ward and  toward  the  median  line.  The  lung  feels  softer  than  normal 
and  puffy  to  the  touch.  Indentation  made  by  digital  pressure  remains 
for  some  time. 

There  is  loss  of  elasticity,  diminished  crepitation,  and  greater  buoy- 
ancy in  water.  Dilated  air  sacs  may  be  seen  protruding  from  the  sur- 
face as  rounded,  hemispherical,  or  spherical  elevations  and  of  a  grayish 
hue.  Air  may  be  pressed  from  the  distended  sacs,  which  upon  section 
appear  as  cavities  scattered  through  the  lung,  varying  in  size  from  a 
millet-seed  to  a  hen's  egg.  In  mild  or  beginning  emphysema  there  may 
be  simply  extreme  distention  of  the  alveoli,  with  little  or  no  destruction 
of  their  walls.  As  the  process  continues,  two  or  more  air  cells  coalesce, 
by  the  rupture  of  their  common  septa,  forming  cavities  of  variable  size. 
The  walls  of  these  are  here  and  there  constricted  and  roughened  by 
ragged  projections  which  mark  the  location  of  former  alveolar  partitions. 
The  capillary  plexus  is  consequently  partially  destroyed.  In  the  inter- 
lobular form,  secondary  to  vesicular  emphysema,  air  escapes  from  the 
vesicles  into  the  interstitial  connective  tissue  forming  other  cavities. 
The  process  may  extend  along  the  blood-vessels  of  the  interlobular  septa 
to  invade  the  mediastinal,  cervical,  and  finally  the  subcutaneous  connec- 
tive tissue. 

Probably  rupture  of  the  alveolar  walls  is  dependent  in  most  cases 
upon  a  primary  fatty  or  fibroid  degeneration.  Senile  emphysema,  so 
called,  results  from  atrophy  of  lung  tissue;  here  the  lungs  are  diminished 
in  size  and  generally  pigmented.  Emphysema  is  generally  bilateral,  but 
may  be  confined  to  one  lung  or  to  a  single  lobe.  When  due  to  forced 
expiration,  with  obstruction  in  the  trachea,  larynx,  or  glottis,  it  is  most 
marked  along  the  anterior  border  of  the  upper  lobes.  In  addition  to  these 
morbid  changes,  the  bronchi  communicating  with  the  cavities  are  the 
seat  of  more  or  less  bronchitis  and  bronchiectasis.  Virchow,  as  reported 
in  1889,  had  never  seen  tubercles  in  an  emphysematous  lung  and  only 
one   case   of  pneumothorax  (Berliner  Tclinische    Wocliensclirift,  1889). 


108  PULMONARY  DISEASES. 

But  both  these  conditions  may  accompany  it.  Pneumonia  occasionally 
complicates  it,  and  dilatation  and  hypertrophy  of  the  heart,  with  re- 
sulting changes  in  the  lungs,  liver  or  kidneys,  are  not  uncommon. 

Etiology. — Emphysema  may  occur  at  any  age.  It  is,  however, 
most  common  in  those  beyond  middle  life,  and  more  frequent  in  men 
than  in  women.  Heredity  seems  to  play  an  important  part  in  the  eti- 
ology; but  whether  the  disease  is  largely  due  to  hereditary  transmission 
of  a  special  weakness  of  lung  tissue,  or  to  primary  malnutritive  changes 
of  a  fatty  or  fibroid  nature,  is  an  open  question.  It  occurs  in  the  aged, 
from  natural  atrophy  accompanying  general  senile  decline.  Forced  in- 
spiration may  cause  over-distention  or  rupture  of  air  vesicles,  whose  elas- 
ticity is  already  impaired.  The  usual  cause  is  the  exertion,  after  deep 
inspiration,  of  powerful  expiratory  efforts  with  closed  glottis  or  with 
more  or  less  obstruction  of  the  respiratory  passages  from  other  causes. 
Hence,  the  disease  not  infrequently  complicates  asthma  and  the  cough 
of  chronic  bronchitis  or  pertussis,  and  may  result  from  excessive  use  of 
certain  wind  instruments,  or  from  straining  efforts  as  in  lifting,  child- 
bearing,  or  defecation.  Local  compensatory  emphysema  occurs  in  the 
air  vesicles  adjacent  to  lung  tissue  that  is  collapsed  or  consolidated  or 
whose  larger  bronchi  have  been  obstructed.  Obliteration  of  the  air  vesi- 
cles of  one  lung  wholly  or  in  large  part,  from  pneumonia,  phthisis,  in- 
farction, and  the  like,  or  from  pressure  by  pleuritic  effusion,  may  produce 
compensatory  emphysema  in  the  opposite  organ. 

Symptomatology. — The  prominent  symptoms  are  constant  dyspnoea, 
increased  on  exertion,  associated  often  with  the  symptoms  of  bronchitis 
or  asthma,  or  of  both. 

The  prominent  signs  are:  lifting  of  the  sternum  in  inspiration, 
barrel-shaped  chest;  vesiculotympanitic  resonance,  and  prolonged  ex- 
piration. 

Inspection  in  well-marked  cases  finds  the  countenance  dusky,  the 
eyes  prominent,  the  nostrils  dilated,  and  the  sterno-cleido-mastoid  mus- 
cles standing  out  like  whip-cords  in  their  efforts  to  aid  in  respiration. 
The  shoulders  are  elevated  and  drawn  forward,  the  neck  is  apparently 
shortened,  and  the  individual  seems  to  stoop,  which  gives  him  the  ap- 
pearance of  old  age.  The  margins  of  the  scapulae  sometimes  stand  out 
like  wings,  and  there  is  an  increase  in  the  antero-posterior  diameter  of 
the  chest,  giving  the  rounded  barrel-shaped  appearance.  During  inspi- 
ration, there  is  no  expansive  movement  of  the  upper  ribs,  but  they  are 
elevated  as  if  the  chest  walls  were  composed  of  a  single  bone.  In  marked 
cases  of  this  disease,  there  is  with  inspiration  falling  in  of  the  soft  parts 
of  the  chest  above  the  clavicles  and  sternum ;  the  intercostal  spaces  at 
the  upper  part  of  the  chest  are  wider  and  more  distinct  than  usual ;  and 
there  is  retraction  instead  of  expansion  of  the  false  ribs  during  inspira- 
tion. Early  in  the  disease,  these  signs  are  not  present.  Venous  pulsa- 
tion is  sometimes  seen  in  the  jugulars. 


PULMONARY  EMPHYSEMA.  109 

Occasionally  among  old  people,  in  cases  known  as  atrophous  emphysema,  the 
intervesicular  septa  are  destroyed  by  atrophy  and  the  vesicles  coalesce.  The 
volume  of  the  lung  is  thereby  more  or  less  diminished,  so  that  the  disease  causes 
no  distention  of  the  chest.  In  such  cases,  no  signs  would  be  obtained  on  in- 
spection, except  perhaps  retraction  and  an  increased  obliquity  of  the  lower  ribs, 
with  considerable  diminution  of  the  space  between  them  and  the  crest  of  the 
ilium. 

By  palpation,  the  apex  beat  of  the  heart  is  frequently  found  below 
its  normal  position,  and  nearer  the  median  line. 

Vocal  fremitus  may  be  exaggerated,  diminished,  or  normal. 

Mensuration  shows  us  the  exact  increase  in  the  antero-posterior  diam- 
eter of  the  chest,  and  the  deficient  expansive  movement  in  inspiration. 

Percussion  yields  vesiculo-tympanitic  resonance.,  usually  most  marked 
over  the  upper  part  of  the  left  lung.  Percussion  over  the  prascordia 
may  show  diminished  area  of  superficial  cardiac  dulness,  or  the  entire 
region  may  yield  pulmonary  resonance,  due  to  the  expansion  of  the 
border  of  the  left  lung,  so  that  it  completely  covers  the  heart. 

Deep  inspiration  or  forced  expiration  will  not  materially  affect  the 
pulmonary^  resonance,  as  it  would  in  health. 

On  auscultation,  the  vesicular  murmur  is  impaired,  the  inspiratory 
sound  being  deferred,  and  consequently  shortened,  and  the  expiratory 
sound  being  prolonged,  so  that  the  ratio  between  the  two  may  be  re- 
versed, making  the  expiratory  sound  equal  in  length  to  the  inspiratory, 
or  even  three  or  four  times  as  long.  In  typical,  uncomplicated  cases, 
both  sounds  are  low  in  pitch;  but  harsh, blowing  sounds  from  the  bron- 
chial tubes  are  often  heard,  especially  during  inspiration.  A  peculiar 
dry,  crackling  sound,  closely  resembling  fine  pleuritic  friction,  is  often 
heard  just  at  the  end  of  inspiration  or  at  the  beginning  of  expiration. 
It  is  produced  in  the  walls  of  the  air-vesicles. 

Gerhardt  {Berliner  Minische  Wochenschrift,  1888),  in  four  cases  of  emphy- 
sema, heard  fine  bubbling,  crackling  sounds  in  the  cardiac  region  synchronous 
with  the  heart-beat,  evidently  from  displacement  of  air  in  the  mediastinal 
connective  tissue  by  the  cardiac  impulse. 

In  rare  cases,  especially  in  the  aged,  the  inspiratory  and  the  expiratory 
sounds  are  of  equal  duration,  exaggerated  in  intensity,  harsh  and  tubular  in 
quality,  and  high  in  pitch.  This  is  probably  due  to  atrophy  of  a  portion  of  the 
lung  tissue. 

Vocal  resonance  may  be  either  increased  or  diminished. 

The  heart-sounds  are  usually  feeble,  and  those  at  the  apex  are  dis- 
placed downward  and  inward,  by  the  intervention  of  the  emphysematous 
lung  between  this  organ  and  the  surface  of  the  chest.  The  cardiac 
sounds  and  impulse  are  often  abnormally  distinct  in  the  epigastric 
region,  due  to  displacement  of  the  heart  and  to  dilatation  of  the  right 
ventricle.  Dilatation  of  the  ventricle  may  cause  tricuspid  regurgitation 
with  a  valvular  murmur. 


110  PULMONARY  DISEASES. 

Diagnosis. — The  diseases  likely  to  be  mistaken  for  emphysema 
are:  dilatation  of  the  lung  from  acute  tuberculosis,  and  pneumo- 
thorax. When  confined  to  one  lung,  emphysema  may  be  mistaken 
for  any  of  the  diseases  which  usually  cause  feeble  respiration.  In 
such  cases,  the  normal  murmur  of  the  sound  side  is  liable  to  be  mistaken 
for  exaggerated  respiration,  and  the  feeble  murmur  of  the  emphysema- 
tous lung  for  the  normal  sounds.  Error  may  be  avoided  by  remember- 
ing that  the  feeble  respiratory  murmur  of  emphysema  is  characterized 
by  prolonged  expiration,  and  that  resonance  over  the  affected  lung  is 
more  marked  than  that  of  the  sound  side ;  while  in  nearly  all  diseases 
causing  feeble  respiration,  from  obstruction  in  the  air  passages  or  from 
interference  with  the  free  expansion  of  the  lung,  the  expiratory  sound 
is  shorter  than  the  inspiratory,  and  the  resonance  is  less  intense  than  on 
the  sound  side.  Emphysema  of  one  lung,  or  of  a  single  lobe  of  one 
lung,  is  a  rare  affection;  but  when  it  does  occur,  great  care  is  necessary 
to  avoid  errors  in  diagnosis. 

Bilateral  emphysema  is  differentiated  from  pneumothorax  by  the  signs 
furnished  upon  inspection,  percussion,  and  auscultation,  as  follows: 

Emphysema.  Pneumothorax. 

Inspection. 
Usually  bilateral.  Very  rarely  bilateral. 

Prominence  of  both  sides,  especially  Uniform  distention  of  one  side,  no 

of  the  antero-superior  portion  of  the        sinking  in  of  the  soft  parts  during  in- 
chest, with  falling  in  of  the  soft  parts        spiration. 
during  inspiration. 

Percussion. 
Vesiculo-tympanitic    resonance    on  Tympanitic  resonance   on  one  side 

both  sides.  only. 

Auscultation. 

The  respiratory  murmur  vesicular  The  respiratory  murmur  feeble  or 

in  quality,  and  expiration  prolonged.  suppressed,  or  amphoric. 

Emphysema  of  a  single  lung  is  distinguished  from  pneumothorax  by 
the  following  signs: 

Emphysema  of  one  lung.  Pneumothorax. 

Percussion. 
Vesiculo-tympanitic  resonance.  Tympanitic  resonance  more  or  less 

intense,  with  absence  of  the  vesicular 
quality. 
Auscultation. 
The  inspiratory  murmur  delayed,  the  The    vesicular    murmur    feeble    or 

expiratory  sound  prolonged.  absent,     but,     if    heard,     regular    in 

rhythm.     The  respiration  may  be  am- 
phoric. 

R.  Thompson  states  that  in  acute  tuberculosis,  as  numbers  of  the  air 


PULMONARY  EMPHYSEMA.  Ill 

vesicles  become  filled  with  the  tubercular  deposit,  the  adjoining  cells 
become  distended  so  as  to  cause  physical  signs,  especially  in  front,  al- 
most identical  with  those  of  emphysema.  The  distinctive  features  of 
the  two  diseases  may  be  seen  in  the  following  table : 

Emphysema.  Acute  tuberculosis. 

History. 

Affection  gradually  developed.  Comparatively  rapid  accession. 

Symptoms. 
Constitutional  symptoms  of  ten  slight.  Constitutional  symptoms  similar  to 

those  of  typhoid  fever. 

Inspection. 
Cyanosis  ;  labored  expiration  ;  chest  Pallor  ;   respirations  rapid  but  not 

enlarged.  labored  ;  chest  not  enlarged. 

Percussion. 
*  Vesiculotympanitic  resonance  more  Vesiculo-tympanitic     resonance    in 

or  less  marked  over  whole  chest.  front,  but  actual  dulness  behind. 

Auscultation. 
Expiratory  murmur  prolonged  and  Expiratory  murmur  not  much  pro- 

low  in  pitch.  longed  and  higher  in  pitch  than  normal. 

Some  signs  produced  by  fibrosis  or  fibroid  disease  of  both  lungs  are 
liable  to  cause  it  to  be  mistaken  for  emphysema.  The  distinction  may 
be  readily  made  from  the  following  signs : 

Emphysema.  Fibroid  disease  of  both  lungs. 

Inspection. 
Fixity  of  the  chest  with  bulging,  ex-  Fixity  of  the  chest  with  flattening. 

cept  in  the  atrophous  form. 

Palpation. 
Vocal  fremitus  usually  diminished.  Vocal  fremitus  markedly  increased. 

Percussion. 
Vesiculo-tympanitic  resonance.  Usually    dulness,    but    occasionally 

resonance  approaching  tympanitic  in 
quality. 
Heart  covered    by  lung  tissue,    as  Heart  uncovered,  causing  increased 

shown  by  resonance.  area  of  superficial  dulness. 

Auscultation. 
Low  -  pitched    respiratory    sounds,  Absence  of  respiratory   murmur  at 

though  sometimes  considerable  harsh-  times.  In  other  instances,  rude  res- 
ness  from  affection  of  the  bronchi.  piration. 

Emphysema  and  bronchial  asthma  are  not  likely  to  be  mistaken  for 
each  other,  especially  if  the  following  points  are  remembered : 

Emphysema.  Asthma. 

History. 

Dyspnoea  constant.  Dyspnoea  paroxysmal. 


112  PULMONARY  DISEASES. 

Emphysema.  Asthma. 

Inspection. 
Chest  barrel-shaped.  Chest  normal. 

Heart  displaced.  Heart  not  displaced. 

Auscultation. 
Few  rales  present  unless  bronchitis  Abundant  dry  rales,  sibilant  and  so- 

complicate,  when  rales  are  moist.  norous. 

Prognosis. — A  lung  once  emphysematous  never  recovers.  Mild  cases 
dependent  upon  causes  which  may  be  early  removed  may  be  greatly  re 
lieved  by  the  general  improvement  of  the  patient  and  the  compensa- 
tion offered  by  the  remaining  normal  lung  tissue.  Though  in  itself  not 
a  dangerous  disease,  well-marked  emphysema  insures  the  patient  much 
distress,  unfits  him  for  active  life,  and  greatly  predisposes  him  to  more 
serious  disease.  Bronchitis,  though  frequently  a  cause  of  the  disease,  is 
a  common  effect.  Bronchiectasis,  asthma,  and  pleurisy  are  likewise  fre- 
quent complications. 

Heart  disease  with  disorders  of  the  liver,  kidneys,  spleen,  and  alimen- 
tary tract  which  are  its  common  sequela?,  naturally  results  from  chronic 
obstruction  to  pulmonary  circulation,  and  is  therefore  an  important  ele- 
ment in  prognosis.  Pneumonia,  tuberculosis,  and  hemorrhage  are  rarely 
observed  in  emphysematous  foci,  but  may  occur  in  parts  not  so  affected. 

Treatment. — As  the  changes  in  the  lung  tissue  in  this  disease  are 
due  in  part  to  general  malnutrition,  our  first  aim  in  treatment  must  be 
to  improve  the  general  condition.  Remedies  of  most  service  for  this 
purpose  are  tincture  of  iron,  cod-lirer  oil,  and  occasionally  small  doses 
of  quinine  and  strychnine. 

Chronic  bronchitis  usually  coexists,  and  should  receive  treatment 
similar  to  that  already  mentioned  under  JJ(ie  head  of  treatment  of  pneumo- 
thorax and  pneumo-hydrothorax.  Potassium  iodide  is  the  most  servicea- 
ble single  remedy  in  this  disease.  It  should  be  given  in  doses  of  gr.  v. 
to  xx.,  three  or  four  times  a  day  for  a  long  time.  Arsenious  acid  long 
continued  has  been  found  beneficial.  Asthmatic  symptoms  are  to  be 
treated  as  spasmodic  asthma.  Cough  may  require  anodynes.  Expira- 
tion into  rarefied  air  has  benefited  some  cases. 

The  patient  must  avoid  all  causes  of  cold  or  asthmatic  attacks,  and 
should  live  if  possible  in  a  climate  where  he  will  be  most  free  from  dysp- 
noea.    High  altitudes  are  not  to  be  recommended  for  these  cases. 


CHAPTER   VIII. 

PULMONARY   DISEASES.— Continued. 

PNEUMONIA. 

Synonyms. — Peripneumonia,  peripneumonia  vera.  Popularly  known 
as  lung  fever  or  inflammation  of  the  lungs.  There  are  two  recognized 
varieties  of  this  disease :  lobar  pneumonia,  in  which  the  greater  part  or  the 
whole  of  one  lobe,  or  the  whole  lung,  is  affected,  and  lobular  pneumonia, 
in  which  the  inflammation  is  confined  to  a  single  lobule,  or  to  groups 
of  lobules  scattered  through  the  lungs.  According  to  the  origin  and 
character  of  the  disease,  its  various  manifestations  collectively  have  also 
been  termed  primary  or  secondary  pneumonia,  or  bilious,  gastric,  ty- 
phoid, latent  or  walking,  intermittent,  hypostatic,  tubercular,  scrofulous, 
rheumatic,  gouty,  puerperal,  or  metastatic  pneumonia — varieties,  so 
called,  which  require  no  special  description.  Though  different  cases  vary 
more  or  less  in  their  origin  and  anatomical  characteristics,  as  well  as  in  a 
few  of  their  clinical  features,  to  attempt  to  differentiate  between  them  by 
their  physical  signs  would  only  be  confusing.  I  shall  therefore  consider 
at  length  only  lobar  and  lobular  pneumonia,  and  but  briefly  mention, 
under  their  respective  headings,  special  variations  of  the  disease,  and 
the  signs  which  are  accounted  valuable  in  enabling  us  to  differentiate 
them. 

LOBAR   PNEUMONIA. 

Synonyms. — Acute  pneumonia;  croupous  pneumonia;  acute  sthenic 
pneumonia. 

Lobar  pneumonia  consists  of  an  inflammation  of  the  vesicular  struc- 
ture of  the  lungs,  with  accumulation  of  inflammatory  exudation  in  the 
air  cells,  whereby  they  are  filled  and  rendered  impervious  to  air. 

Anatomical  and  Pathological  Characteristics.  —  Croupous 
inflammation  of  the  lung  is  characterized  by  three  stages — first  engorge- 
ment, second  red  hepatization,  third  yellow  or  gray  hepatization;  it  may 
terminate  in  resolution,  in  suppuration  diffuse  or  circumscribed,  in  gan- 
grene, in  chronic  pneumonia,  or  in  tuberculosis.  During  engorgement 
the  lung  is  increased  in  size,  is  of  a  dark  red  or  bluish  color,  with  per- 
haps faint  patches  of  subpleural  ecchymoses  and  the  affected  tissue  does 
not  collapse.  It  is  doughy  in  consistency,  pits  on  pressure,  and  is  heavier 
than  normal.     From  the  cut  surface  oozes  a  reddish  sero-albuminous 


1U  PULMONARY  DISEASES. 

fluid,  with  darker  blood  from  the  capillaries.  Microscopically  the  vessels 
lining  the  alveoli  are  found  crowded  with  blood  corpuscles  and  so  dis- 
tended as  to  encroach  upon  the  lumen  of  the  air  sacs,  which  contain 
serum,  corpuscles,  and  a  few  epithelial  cells. 

In  the  stage  of  red  hepatization  the  organ  is  darkly  mottled,  in  color 
resembling  the  liver;  the  serous  surface  may  be  markedly  ecchymotic 
and  the  seat  of  fibrinous  exudation.  The  lung  is  larger,  heavier,  and 
firmer  than  normal ;  it  sinks  in  water,  is  friable,  non-crepitant,  and  may 
show  the  imprint  of  the  ribs.  The  cut  or  torn  surface  is  bathed  in  a 
reddish  serous  fluid,  and  appears  granular  from  the  projection  of  small, 
dark  red  masses  of  coagulum  from  the  alveoli.  These  become  more 
prominent  on  pressure  and  are  easily  removed  upon  scraping  the  surface. 

Microscopically  these  masses  are  seen  to  consist  of  granular  epithelial 
cells  and  red  and  white  corpuscles,  held  within  a  fibrinous  coagulum. 

In  the  third  stage  red  hepatization  gradually  gives  place  to  yellow  or, 
in  markedly  pigmented  lungs,  to  gray  hepatization.  The  red  color  of 
the  former  stage  disappears  owing  to  fatty  degeneration  of  the  alveolar 
contents,  to  anamiia  produced  by  the  pressure  within  the  alveoli,  and  to 
breaking  up  of  the  red  corpuscles  with  some  absorption  of  their  hamiatin. 
The  lung  in  this  stage  is  still  larger  and  heavier  than  in  the  preceding 
stage,  it  is  more  mottled  with  gray  and  yellow,  more  fragile,  and  is  non- 
crepitant.  Section  reveals  a  surface  more  uniformly  gray  or  dirty 
yellow  and  less  granular,  from  which  exudes  a  viscid  fluid  of  like  color. 

Microscopic  examination  shows  pus  cells,  fat  globules,  pigment, 
micro-organisms,  and  a  detritus  of  fibrin  and  red  corpuscles.  The 
morbid  conditions  causing  these  appearances  are  located  chiefly  in  the 
air  sacs.  In  addition,  the  mucous  membrane  of  the  smaller  bronchi  is 
usually  congested  and  not  infrequently  these  are  the  seat  of  plastic, 
fibrinous  casts  sometimes  extending  to  the  larger  tubes.  (Edema  of  the 
parts  adjacent  to  the  inflammatory  focus  is  usually  present  and  may  also 
involve  the  opposite  lung.  Acute  compensatory  emphysema  is  likewise 
occasionally  present.  The  bronchial  glands  enlarge  and  sometimes 
suppurate. 

Pleuritis  occurs  if  the  pneumonia  is  superficial.  Pericarditis  is  most 
common  in  pneumonia  of  the  left  lung,  evidently  from  direct  extension, 
but  it  is  not  an  uncommon  accompaniment  of  right-sided  pneumonia. 
Inflammation  or  at  least  marked  congestion  of  more  remote  structures — 
the  alimentary  tract,  liver,  spleen,  kidneys,  brain,  and  spinal  cord — are 
not  uncommon  associate  morbid  phenomena.  Under  favorable  condi- 
tions, resolution  occurs,  incident  to  rapid  fatty  degeneration  of  the 
alveolar  contents,  which  become  more  fluid  and  disappear  partly  by 
expectoration,  partly  by  absorption.  Gradually  air  re-enters  the  vesicles, 
which  resume  their  function,  congestion  subsides,  and  pulmonary  oedema 
slowly  disappears.  In  unfavorable  cases  suppuration  may  supervene 
upon  the  third  stage;  the  lung  then  becomes  more  uniformly  yellow, 
boggy,  and  very  fragile,  and  the  fluid  from  the  torn  surface  is  decidedly 


LOBAR  PNEUMONIA.  115 

purulent.  There  is  also  more  or  less  purulent  infiltration  of  the  peri- 
vesicular  tissues.  Kesolution  may  slowly  follow  this  diffuse  suppuration, 
or  numerous  abscesses  may  form  by  rupture  of  the  interalveolar  septa 
and  formation  of  limiting  walls  of  granulation  tissue.  These  in  turn, 
by  progressive  ulceration  in  the  line  of  least  resistance,  may  terminate 
in  perforation  of  the  pleura  or  pericardium,  or  may  empty  themselves 
into  the  bronchi  and  close  by  cicatrization ;  or  their  contents  remaining 
encapsulated  may  undergo  caseous  change  and  receive  calcareous  deposit. 
Diffuse  or  circumscribed  gangrene  occasionally  occurs,  invited  in  somg 
cases  by  antecedent  bronchiectasis  or  putrid  bronchitis  (Orth,  Diagnosis 
in  Pathological  Anatomy,  p.  145).  In  rare  cases  acute  pneumonia  termi- 
nates in  a  chronic  form,  characterized  pathologically  by  large  increase  in 
the  interstitial  connective  tissue  which  obliterates  the  alveoli  and  smaller 
bronchi  of  the  affected  part,  making  it  firm,  dense,  and  airless.  Finally, 
the  pneumonic  area  is  liable  to  infection  with  the  tubercle  bacillus.  In 
order  of  comparative  frequency  pneumonia  affects  the  right  lower,  the 
left  lower,  and  the  right  upper  lobe.  According  to  Minot,  the  disease 
in  children  originates  oftenest  in  the  right  upper  lobe,  least  frequently 
in  the  right  lower.  Double  pneumonia  occurs  in  from  five  to  fifteen 
per  cent  of  all  cases,  but  most  frequently  in  the  aged  (Loomis'  Practical 
Medicine,  p.  102;  Cyclopaedia  of  Diseases  of  Children,  p.  589). 

Etiology. — Climates  and  seasons  most  subject  to  sudden  marked 
changes  of  temperature,  occupations  subjecting  the  individual  to  abrupt 
changes  from  heat  to  cold,  and  such  hygienic  conditions  as  bad  ventila- 
tion and  sewerage,  poor  food  and  clothing,  and  habits  which  enervate 
are  all  favorable  to  the  occurrence  of  pneumonia.  Though  robust  health 
and  a  fine  physique  seem  at  times  to  offer  to  it  no  barriers,  yet  most 
diseases  which  exhaust  vitality  and  diminish  local  resistance  predispose 
to  pneumonia.  In  this  category  are  included  a  previous  attack  of  pneu- 
monitis, the  acute  infectious  diseases,  alcoholism,  uraemia,  acute  rheu- 
matism, and  disorders  of  the  blood.  Diseases  of  the  heart  producing 
chronic  pulmonary  congestion,  and  severe  traumatic  injuries  to  the 
chest,  are  also  predisposing  factors. 

Recent  investigations  by  Fraenkel,  Weichselbaum,  Friedlander,  Netter, 
Sternberg  and  many  other  careful  observers  suggest  that  pneumonia  is  an  in- 
fectious disease,  the  primary  exciting  cause  of  which  is  a  specific  micro-organism ; 
and  that  in  most  instances  the  diplococcus  pneumoniae  of  Fraenkel  is  that  germ. 
According  to  these  writers,  it  can  be  proved  to  exist  in  over  90  per  cent  of  all  cases, 
in  the  tissues  and  fluids  of  the  local  pulmonary  inflammation  ;  and  it  has  also 
been  found  at  the  seat  of  complicating  meningitis,  pleuritis,  pericarditis,  synovitis, 
and  otitis.  Friedlander' s  micrococcus,  the  typhoid  bacillus,  and  other  specific 
germs  may  also  in  some  cases  excite  pulmonary  inflammation.  Delafield  (Neio 
York  Med.  Jour.,  1890)  regards  pneumonia  as  an  infective  inflammation  de- 
pendent upon  individual  susceptibility,  a  primary  exciting  cause  of  inflammation 
and  a  pathogenic  bacterium  some  one  of  which  factors  takes  precedence  at  differ- 
ent times.     Facts  recorded  by  "Wolff  (Zeitschrift  der  Bakt.,   1890),    Jaworski 


116  PULMONARY  DISEAS1 

(Jour.  Am.  Med.  Ass.,  Dec,  1889),  Kuhn  (Berlin  klin.  Woch.,  April,  1889), 
Mutheson  (Brooklyn  Mi  d.  Jour.,  April,  1889),  Wagner  (Am.  Jour.  Med.  Sci.,  1889), 
Wells  (Med.  Regist.,  Feb.,  1890;  N.  Y.  Med.  Jour.,  March,  1890),  Mosler  (I)eut. 
med.  Work.,  Nos.  13  and  14,  1890;  Med.  Press  and  Circ,  Sept.  25,  1890),  and 
others  strongly  suggest  its  contagious  character  under  some  conditions. 

Symptomatology. — The  chief  symptoms  are  a  severe  initial  chill, 
followed  by  fever  which  attains  great  intensity  in  a  few  hours  and  as 
suddenly  subsides  between  the  fifth  and  the  tenth  days ;  these  are  usually 
attended  by  pain  in  the  side,  dyspncea,  cough  with  clear  tenacious  and 
subsequently  rusty  sputa,  great  prostration,  and  frequently  delirium. 

In  some  cases  these  active  features  are  preceded  several  days  by  dull 
pains  in  the  head,  back,  and  limbs,  dizziness,  lassitude,  and  perhaps  ali- 
mentary disorders.  Usually  the  onset  manifests  itself  abruptly  by  severe 
rigors,  which  may  Last  for  two  or  three  hours.  In  children  there  may 
also  be  initial  convulsions,  delirium,  and  gastric  disturbance.  The  tem- 
perature in  uncomplicated  pneumonia  is  characterized  generally  by  a 
rise  to  103°  or  105°  F.  at  the  invasion,  followed  by  slight  morning  re- 
missions and  evening  exacerbations  till  the  day  of  crisis,  when  it  either 
declines  gradually  or  falls  suddenly  to  normal  or  one  or  two  degrees 
below.  The  highest  point  is  commonly  reached  on  the  second  or  third 
day,  but  may  occur  just  before  the  final  fall. 

The  pulse  ranges  from  100  to  120  beats  per  minute,  or  much  higher 
in  serious  cases,  and  is  the  most  important  index  in  pneumonia.  It 
becomes  rapid  and  feeble  depending  upon  the  severity  and  duration  of 
the  attack,  and  may  be  intermittent,  especially  in  old  age. 

Sharp  lancinating  pain  below  the  nipple,  increased  by  cough  and  deep 
inspiration,  is  a  common  symptom,  probably  due  to  concomitant  pleuri- 
tis.  It  may  be  absent  or  slight  in  old  age  and  when  the  pneumonia  is 
deep  seated.  It  tends  to  diminish  and  disappear  by  the  third  or  fourth 
day.  Very  severe  headache  during  the  first  two  or  three  days  is  an  al- 
most constant  symptom.  Delirium,  usually  of  the  mild,  incoherent  type, 
is  most  frequent  in  old  people,  children,  and  drunkards;  in  the  latter  it 
may  take  the  violent  form.  Muscular  tremors  are  common  in  conva- 
lescence. Convulsions  often  occur  in  children  either  at  the  beginning 
of  the  disease  or  just  before  death.  Respiration  is  shallow  and  increased 
in  rapidity,  in  severe  cases  even  to  sixty  or  seventy  counts  to  the  minute. 
Dyspnoea  is  usually  an  early  and  prominent  symptom,  but  may  be  absent, 
even  with  greatly  accelerated  breathing. 

Cough  of  a  short,  hacking  character  is  commonly  an  early  symptom, 
but  is  exceptionally  absent.  It  may  disappear  just  before  death.  The 
expectoration,  at  first  frothy,  becomes  translucent,  tenacious,  and  viscid, 
and  later  of  a  red  or  brownish-red  brick-dust  or  rusty  color  from  ad- 
mixture of  blood.  In  some  grave  cases  the  sputum  is  more  watery  and 
dark  purple,  like  prune  juice.  Rusty  sputum  commonly  appears  within 
the  first  two  or  three  days,  but  may  be  absent  till  the  tenth  or  twelfth, 


LOBAR  PNEUMONIA. 


117 


and  then  present  in  but  slight  degree.  Earely,  it  is  entirely  absent.  Dur- 
ing resolution  the  sputum  is  more  profuse  and  yellow  or  greenish.  Diges- 
tive disorders,  vomiting,  and  diarrhoea  occur  sometimes  at  the  invasion. 
The  essential  signs  in  the  order  of  their  occurrence  are :  diminished 
movement  of  the  side,  some  dulness  and  crepitant  rales,  followed  by 
marked  dulness,  bronchial  breathing,  and  bronchophony.  These  signs 
are  succeeded  in  favorable  cases  by  subcrepitant  rales  and  a  gradual  re- 
turn of  the  healthy  signs  (Fig.  27). 


Normal  signs. 


Bronchial  breathing  I 
and  bronchophony.       ) 


Subcrepitant  rales. 


Fig.  27.— The  upper  lobe  indicates  healthy  lung  tissue  ;  the  middle  lobe  represents  the  second 
stage  of  pneumonia  (red  hepatization),  and  the  lower  lobe  illustrates  the  third  stage  (gray  hep- 
atization). 

For  convenience  we  describe  the  signs  in  three  groups  corresponding 
to  the  three  stages  of  the  disease.  The  first  stage,  beginning  with  the 
inception  of  the  disease,  continues  until  the  air  vesicles  are  completely 
filled.  From  this  point  the  second  stage  continues  throughout  the  period 
of  consolidation  or  red  hepatization.  The  third  stage,  that  of  gray 
hepatization,  continues  from  the  beginning  of  resolution  until  convales- 
cence is  complete. 

As  signs  of  the  first  stage,  inspection  finds  the  movements  of  the 
chest  somewhat  diminished  over  the  affected  organ. 

Palpation  in  the  early  part  of  this  stage  yields  only  negative  results; 
later,  the  vocal  fremitus  is  increased. 

Percussion  early  in  this  stage  elicits  slight  dulness,  which  gradually 
increases  as  the  stage  advances. 

On  auscultation,  while  there  is  congestion  only,  before  inflammation 
has  become  fairly  established,  the  respiratory  murmur  is  feeble.  As 
exudation  takes  place,  crepitant  rales  occur  in  great  numbers  at  the  end 
of  inspiration.  When  these  rales  are  well  marked  and  persistent,  they 
may  be  regarded  as  pathognomonic. 


118  PULMONARY  DISEASES. 

When  pneumonia  is  associated  with  inflammatory  rheumatism,  the  crepitant 
rale  does  not  occur.  Subcrepitant  are  sometimes  associated  with  the  crepitant 
rales,  but  the  latter  greatly  predominate. 

As  consolidation  progresses,  respiration  becomes  broncho-vesicular 
and  finally  bronchial. 

As  signs  of  the  second  stage,  inspection  and  palpation  show  that  the 
movements  are  still  deficient  on  tbe  affected  side,  and  exaggerated  on 
the  opposite  side.     Vocal  fremitus  is  exaggerated. 

Exceptional. — Consolidation  in  rare  instances  diminishes  the  vocal  fremitus, 
in  consequence  of  complete  occlusion  of  the  bronchial  tubes. 

In  percussion  there  is  marked  dulness  over  the  affected  area,  with 
exaggerated  resonance  over  healthy  portions.  The  line  separating  dul- 
ness from  vesicular  resonance  usually  corresponds  to  the  position  of  the 
interlobular  fissure,  and  is  not  altered  by  changes  in  the  position  of  the 
patient. 

Exceptional. — In  rare  cases  the  density  of  the  lung  is  so  great  that  the  per- 
cussion sound  caused  by  vibration  of  air  in  the  bronchial  tubes  is  transmitted  to 
the  surface  with  such  peculiar  distinctness  as  to  justify  the  appellation  of  tubular 
resonance.  In  some  instances  of  extreme  consolidation,  the  resonance  seems  al- 
most amphoric.  In  such  cases  the  solid  sounds  would  of  necessity  be  mistaken  for 
hollow  sounds,  were  it  not  for  their  pitch,  which  is  always  high  instead  of  low 
like  the  proper  resonance  of  cavities.  In  rare  cases,  flatness  is  found  instead  of 
dulness. 

By  auscultation  there  are  found  no  crepitant  rales,  but  in  their  place 
we  find  bronchial  or  broncho-vesicular  respiration,  varying  in  degree 
with  the  amount  of  consolidation.  There  is  also  coexisting  bronchoph- 
ony and  whispering  bronchophony.  A  few  moist  and  dry  bronchial 
rales  are  apt  to  be  heard  in  this  stage. 

Exceptional. — In  rare  cases  a  few  crepitant  rales  may  be  heard  in  this  stage. 
In  other  instances,  the  bronchial  tubes  of  larger  size  may  be  filled  by  the  inflamma- 
tory lymph,  so  that  the  vocal  resonance  is  diminished  instead  of  being  intensified, 
and  all  respiratory  sounds  may  be  suppressed. 

Early  in  the  third  stage,  the  signs  are  the  same  as  in  the  second  stage, 
with  the  addition  of  a  few  subcrepitant  rales.  As  the  stage  advances, 
vocal  fremitus  becomes  gradually  lessened,  dulness  diminishes  over  the 
inflamed  portion  of  the  lung,  bronchial  breathing  slowly  gives  place  to 
broncho-vesicular  breathing,  and  this  finally  to  the  normal  respiratory 
murmur.  Subcrepitant  rales  appear  early  in  this  stage,  and  continue, 
often  associated  with  mucous  rales  in  the  larger  bronchi,  until  resolution 
is  nearly  complete. 

The  crepitant  rale  also  occasionally  reappears;  it  is  then  known  as 
the  crepitant  rale  redux. 

Bronchophony,  which   was  present   in  the  second  stage,  gradually 


LOBAR  PNEUMONIA.  119 

gives  place  to  exaggerated  vocal  resonance,  and  this,  in  turn,  to  the 
normal  sonnds  of  the  voice. 

Diagnosis. — Pneumonia  is  to  be  diagnosticated  from  pleurodynia, 
intercostal  neuralgia,  pleurisy,  pulmonary  oedema,  collapse  of  the  air 
vesicles,  hydrothorax,  phthisis,  and  bronchitis;  also,  in  children,  from 
meningitis  on  account  of  the  delirium,  occasional  contractions  of  the 
posterior  cervical  muscles  and  other  convulsive  phenomena.  In  the  aged 
or  debilitated,  on  account  of  the  typhoid  symptoms  and  occasional 
absence  of  the  usual  symptoms  of  inflammation  of  the  lung,  it  may  be 
mistaken  for  typhoid  fever. 

It  is  not  likely  to  be  mistaken  for  pleurodynia  or  intercostal  neural- 
gia by  any  one  familiar  with  physical  diagnosis,  as  these  diseases  yield 
no  signs  excepting  those  due  to  pain. 

From  pleurisy  it  is  distinguished  by  the  following  features : 

Pnecjioxia.  Pleurisy. 

Symptoms. 

Deep-seated,  comparatively  dull  pain,  Pain    superficial,    and  lancinating, 

marked  chill,  high  temperature,  cough      usually  absence  of  marked  chill  and 

with  viscid  or  rusty  sputum.  high  temperature,    absence  of   rusty 

and  viscid  sputum. 

Signs. 

First  Stage.  First  Stage. 

Moderate  dulness  with  feeble  respi-  Resonance     normal.      Respiratory 

ration.    Numerous  crepitant  rales  only        murmur  feeble  or  absent.    Ordinarily 

on  inspiration,  and  exaggerated  vocal        grazing  or  creaking  friction  sounds, 

resonance.  both  inspiratory  and  expiratory  ;   but 

occasionally  transitory  crepitating 
friction  murmurs  few  in  number  as 
compared  with  crepitant  rales  usu- 
ally heard  during  three  or  four  inspira- 
tions, then  disappearing,  to  return  in 
a  few  moments. 

Second.  Stage.  Second  Stage. 

Vocal  fremitus  exaggerated.      Dul-  Vocal  fremitus  absent.     Flatness  in- 

ness  marked  with  no  change  of  the  up-  stead  of  dulness.     The  line  of  flatness 

per  limit  by  changes  in  the  position  of  changes  with  changes  in  the  patient's 

the  patient.  position. 

Bronchial     respiration     and     bron-  Usually  absence  or  marked  feeble- 

chophony .  ness  of  all  respiratory  and  vocal  sounds. 

Third  Stage.  TJi ird  Stage . 

Subcrepitant  rales  in  addition  to  the  Friction  fremitus  and  murmur  ;  ab- 

harsh  respiration,  exaggerated  vocal  sence  of  rales.     Respiratory  and  vocal 

fremitus,  and  resonance,  and  dulness  of  signs  feeble  or  nearly  normal.     More 

the  second  stage.  or  less  dulness. 

There  is  a  liability  to  mistake  pulmonary  aidema  only  for  the  first 
and  third  stages  of  pneumonia.     The  diagnosis  is  generally  easily  made 


120  PULMONARY  DISEASES. 

if  we  recollect  that  oedema  is  usually  a  bilateral,  and  pneumonia  a  uni- 
lateral disease.  In  oedema,  the  dulness  is  slight,  and  occurs  on  both  sides; 
while  in  pneumonia  it  is  marked,  and  commonly  found  only  on  one  side. 

Crepitant  rales  are  few  in  oedema  and  nearly  always  associated  with 
larger  moist  rales.  In  the  first  stage  of  pneumonia  crepitant  rales  are 
very  abundant,  ami  seldom  associated  with  other  moist  sounds. 

Subcrepitant  rales  in  oedema  are  heard  upon  both  sides,  and  are  not 
high  in  pitch  or  metallic  in  quality.  In  pneumonia  they  are  found  only 
on  one  side,  and  are  high  in  pitch  and  usually  metallic. 

(Edema  usually  follows  some  protracted  disease,  as,  typhoid  fever. 
Pneumonia  is  generally  a  primary  affection,  and  is  attended  by  marked 
febrile  symptoms  which  are  absent  in  oedema. 

Pneumonia  is  distinguished  from  pulmonary  collapse  or  atelectasis  by 
the  history  and  ensemble  of  physical  signs,  rather  than  by  any  pathog- 
nomonic characteristics.  The  points  of  distinction  are  shown  in  the 
following  table : 

Pneumonia.  Pulmonary  collapse. 

History. 
Usually  a  primary  affection  invoiv-  Generally    a    sequel   of    bronchitis, 

ing  only  one  lung.  often  involving  both  lungs. 

Percussion. 
Marked  dulness.  Moderate  dulness,  frequently  vesicu- 

lotympanitic resonance  in  the  vicinity. 

Auscultation. 

In  the  tirst  and  third  stages,  crepitant  Few  if  any  crepitant  or  subcrepitant 

and  subcrepitant  rales.  rales. 

Second  stage,   bronchial  breathing ;  Bronchial  breathing  over  collapsed 

exaggerated  respiration  over  healthy  lung  ;  prolonged  emphysematous  ex- 
lung,  piration  near  it. 

Rales  and  other  abnormal  signs  usu-  Rales   due  to  bronchitis   over  both 

ally  confined  to  one  lung  or  one  lobe  of  lungs.  Other  signs  due  to  collapse 
that  lung.  more  apt  to  affect  both  lungs  and  not 

likely  to  involve  an  entire  lobe  of 
either. 

The  distinction  between  pneumonia  and  hydrothorax  is  shown  below : 

Pneumonia.  Hydrothorax. 

Unilateral  dulness,  and  the  respira-  Bilateral   flatness,   with  absence  of 

tory  and  vocal  signs  of  consolidation.  respiratory  and  vocal  signs. 

To  distinguish  pneumonia  horn  phthisis,  a  knowledge  of  the  history 
and  the  symptoms  is  frequently  essential.  Many  physicians,  where  the 
signs  of  pneumonia  have  continued  for  more  than  four  or  five  weeks, 
consider  the  case  one  of  consumption ;  but  this  rule  will  not  always  hold 
good.  The  distinctive  features  between  these  two  diseases,  as  they  ordi- 
narily present  themselves,  may  be  seen  in  the  following  table : 


LOBAR  PNEUMONIA.  121 

Pneumonia.  Phthisis. 

An  acute  affection  usually  involving  A.  protracted  disease  coming  on  in- 

the  greater  portion  of  the  lower  lobe  sidiously,  nearly  always  beginning  at 
of  one  lung  and  giving  rise  to  the  signs  the  apex  of  the  lung,  and  at  first  in- 
of  consolidation .  volving    only    a    limited    amount   of 

tissue  ;  giving  rise,  first,  to  the  signs 
of  slight  and  subsequently  to  those  of 
greater  consolidation. 

Symptoms. 
Breathing  panting.    Marked  pyrexia  Breathing-  hurried  but  natural.     Ir- 

terminating  in  crisis.  regular  and  intermittent  temperature. 

Microscopic. 
Pneumococci.  Tubercle  bacilli. 

Phthisis  following  upon  pneumonia  will  be  distinguished  from  piu- 
longed  cases  of  the  simple  inflammation  by  the  history  and  by  the 
physical  signs  obtained  on  repeated  examinations,  and  in  most  cases  by 
finding  tubercle  bacilli  in  the  sputum. 

Any  one  familiar  with  physical  diagnosis  cannot  mistake  bronchitis 
for  the  early  stages  of  pneumonia.  The  rales  of  the  resolving  stage  of 
pneumonia  might  be  mistaken  for  those  of  bronchitis ;  but  there  is  no 
danger  of  error  if  we  remember  that  the  latter  is  a  bilateral  disease  and 
causes  little  or  no  dulness  on  percussion,  and  that,  when  dulness  does 
occur,  it  disappears  after  cough  and  free  expectoration. 

Though  in  some  cases  the  symptoms  of  pneumonia  are  like  the 
symptoms  of  meningitis  and  typhoid  fever,  the  diagnosis  is  readily  made 
by  careful  physical  examination. 

Prognosis. — Uncomplicated  pneumonia  usually  runs  its  active 
course  in  from  five  to  ten  days.  The  symptoms  increase  till  the  day  of 
crisis,  when  they  suddenly  remit  or  subside  by  lysis.  The  crisis,  usually 
occurring  anywhere  from  the  fifth  to  the  ninth  day,  is  marked  by  a 
sudden  fall  of  temperature,  often  to  one  or  two  degrees  below  normal, 
accompanied  by  decrease  in  severity  of  the  other  symptoms,  and  followed 
by  sleep,  or  in  children  by  stupor.  There  is  also  not  infrequently 
a  critical  hemorrhage  from  the  kidneys,  bowels,  or  nasal  mucous  mem- 
brane, and  usually  a  profuse  perspiration  occurs.  In  the  feeble  or  aged 
the  critical  discharge  may  occur  as  diarrhoea. 

The  mortality  in  pneumonia  ranges  from  ten  to  twenty  per  cent, 
varying  in  different  seasons  and  years,  but  in  the  weak  and  aged  averag- 
ing much  higher.  The  prognosis  is  worse  for  women  than  for  men,  for 
infants  than  for  adults  under  sixty.  In  persons  over  sixty,  and  in  those 
addicted  to  the  excessive  use  of  alcoholic  stimulants,  the  disease  is  ex- 
ceedingly fatal.  In  general,  fatality  is  proportionate  to  the  extent  of 
lung  tissue  involved  and  to  the  severity  of  the  fever.  Double  pneu- 
monia usually  terminates  in  death,  and  pneumonia  of  the  apex  is  said  to 


L252  PULMONARY  DISEASES. 

be  especially  unfavorable  in  the  aged  and  in  children.  Complicating 
pericarditis,  valvular  disease  of  the  heart,  Bright 's  disease,  diabetes, 
pleurisy,  tuberculosis,  emphysema,  and  pulmonary  abscess  or  gangrene 
greatly  lessen  the  chances  of  recovery.  The  most  prominent  unfavorable 
symptoms  are  as  follows:  A  pulse  in  adults  above  120  beats  to  the 
minute,  in  children  above  130,  or  marked  irregularity  in  its  rhythm; 
rapid  respiration  with  low  temperature;  fever  above  104°  F.  for  more 
than  forty-eight  hours;  a  gradual  rise  of  temperature  after  the  fourth, 
or  continued  fever  beyond  the  tenth  day;  delirium  and  coma,  or  in 
children  convulsions  occurring  late;  signs  of  collapse  at  any  stage  of  the 
disease;  haemoptysis  or  copious  prune-juice  expectoration;  suppression 
of  the  sputum  in  the  third  stage  or  its  becoming  fetid.  Death  occurs 
from  asphyxia  or  more  frequently  from  heart  failure. 

Treatment. — Within  the  first  ten  or  fifteen  hours  from  the  incep- 
tion of  the  attack,  a  blister  will  sometimes  prevent  further  development 
of  the  inflammatory  process;  but  patients  are  seldom  seen  by  a  physi- 
cian early  enough  to  allow  of  the  use  of  this  agent.  Calomel  adminis- 
tered in  grain  doses  every  bour  until  its  purgative  effects  are  produced 
is  said  to  abort  some  cases,  but  it  should  not  be  given  to  debilitated 
patients. 

For  the  first  two  or  three  days,  small  doses  of  aconite  or  veratrum 
viride  are  very  useful.  They  should  be  given  often,  in  just  sufficient 
doses  to  keep  the  pulse  nearly  down  to  its  natural  rate ;  they  must  not 
be  continued  after  the  third  day.  During  the  same  period  fluid  ext.  of 
ergot,  in  doses  of  TTlxx.  to  xxx.  every  three  or  four  hours,  is  often  very 
useful,  relieving  congestion  and  checking  the  inflammation. 

After  the  second  day  quinine  in  doses  of  three  to  five  grains  every 
three  to  five  hours  is  the  best  antipyretic.  In  the  inception  of  the  dis- 
ease, phenacetine,  gr.  v.  to  x.,  or  antipyrine  in  similar  doses  are  often 
productive  of  the  best  effects  in  relieving  fever;  but  as  soon  as  the  heart 
begins  to  weaken,  they  should  be  employed,  if  at  all,  with  the  greatest 
caution.  It  is  unsafe  to  use  them  continuously,  and  seldom  desirable  to 
administer  more  tbaft  three  or  four  doses  of  either  in  the  beginning  of 
the  disease,  or  more  than  one  or  two  small  doses  during  any  twenty-four 
hours  after  the  second  day  of  the  attack.  It  should  be  remembered 
that  phenacetine  is  less  depressing  to  the  heart  than  antipyrine,  but 
apparently  possesses  only  about  one- half  the  antipyretic  power. 

During  the  active  stage  of  inflammation,  large,  hot  jacket  poultices, 
enveloping  the  whole  side,  are -beneficial  if  they  can  be  kept  constantly 
and  thoroughly  applied;  otherwise  they  do  harm.  When  poultices  can- 
not be  managed  satisfactorily,  an  oil-silk  jacket  should  be  employed,  with 
warm  clothing.  The  constant  application  of  heat  or  cold  produces  the 
same  results  in  acute  inflammations;  therefore,  in  some  instances  when 
the  temperature  is  high,  excellent  results  may  be  obtained  by  the  appli- 
cation of  cold  over  the  affected  organ ;  preferably  by  means  of  the  coil 


LOBULAR  PNEUMONIA.  123 

of  rubber  tubing  through  which  a  current  of  ice-water  is  kept  circulat- 
ing. From  the  very  first,  the  patient  should  keep  perfectly  quiet, 
neither  moving  nor  speaking  excepting  when  absolutely  necessary. 

Very  small  closes  of  opium  or  moderate  doses  of  chloral  are  some- 
times necessary  to  relieve  pain  and  restlessness,  but  either  must  be  given 
very  carefully,  and  opium  is  especially  objectionable  when  the  evidence 
of  imperfect  aeration  of  blood  is  distinct.  Many  patients  have  undoubt- 
edly been  hurried  to  the  grave  by  tbe  injudicious  use  of  opium  in  this 
disease. 

Where  there  is  much  prostration,  and  the  heart  is  weak,  strychnine 
gr.  -gV  to  ^o  or  tincture  of  nux  vomica  in  full  doses  with  or  without  tinc- 
ture of  digitalis  every  three  or  four  hours  is  very  important.  Alco- 
holics or  ammonium  carbonate  are  required  in  the  same  condition;  and  if 
oedema  of  the  lungs  appears,  alcoholic  stimulants  in  large  and  oft- 
repeated  doses  are  of  the  utmost  importance. 

The  ammonium  salt  is  evanescent  in  its  effects,  but  acts  promptly. 

Ammonium  iodide,  ammonium  chloride,  calcium  chloride,  liquor 
potassse,  or  potassium  acetate  are  useful  in  the  later  stages  to  favor 
resolution  and  prevent  caseation.  Late  in  the  disease  counter-irritation 
is  beneficial.  Cathartics  and  blood-letting  should  not  be  employed  ex- 
cepting in  rare  instances,  in  robust  patients.  When  patients  are  much 
prostrated  and  delirious,  great  care  should  be  taken  to  prevent  them 
from  sitting  up  or  getting  out  of  bed,  for  thisjwill  sometimes  cause  im- 
mediate death. 

Liquid  diet  should  be  given  regularly  during  the  height  of  the  at- 
tack; as  a  rule,  a  half  pint  of  milk  or  its  equivalent  being  given  every 
three  hours. 

The  experiments  of  G.  and  F.  Klemperer  (Berliner  klinische  Wochenschrift)  on 
the  curative  effects  of  the  blood-serum  of  immune  animals,  or  antipneumotoxin, 
are  extremely  interesting,  but  as  yet  the  results  are  not  authenticated. 

LOBULAR   PNEUMONIA. 

Synonyms.  —  Catarrhal  pneumonia;  broncho-pneumonia;  dissem- 
inated pneumonia.  Chronic,  interstitial,  or  interlobular  pneumonia  is 
often  included  in  this  term. 

Lobular  pneumonia  is  an  inflammation  of  single  lobules  or  groups  of 
lobules  scattered  through  the  lung,  preceded  and  accompanied  by  bron- 
chitis. 

ANATOMICAL   AO    PATHOLOGICAL    CHARACTERISTICS. — The    Surface 

of  a  lung,  which  is  the  seat  of  catarrhal  pneumonia,  if  the  disease  is 
superficial,  presents  rounded,  isolated,  reddish-brown  or  gray  spots,  often 
slightly  raised,  varying  in  size  up  to  that  of  a  walnut.  These  may  be 
confined  to  a  lobule  or  may  be  scattered  over  one  or  both  lungs.  At 
these  points  crepitation  is  diminished  or  absent,  the  lung  is  more  fria- 


124  PULMONARY  DISEASES. 

ble  and  cannot  be  inflated.  Section  reveals  a  mottled  appearance  due  to 
isolated  dark  brownish  areas  of  consolidation,  interspersed,  in  advanced 
stages,  with  others  of  a  lighter  hue;  from  the  former,  thick,  reddish 
secretion  escapes,  from  the  latter,  it  has  more  of  a  milky  appearance; 
pus  may  also  be  pressed  from  the  bronchioles.  The  granular  formations 
characteristic  of  the  red  hepatization  of  croupous  pneumonia  are  ab- 
sent in  the  catarrhal  form.  Here  the  nuclei  of  consolidation  are  com- 
posed of  scattered  groups  of  bronchioles  with  their  immediately  related 
resides.  Inflammation  commencing  in  the  bronchioles  involves  the  air 
vesicles  by  direct  extension  or  by  aspiration  into  them  of  irritating  secre- 
tions. The  microscope  shows  some  of  the  alveoli  collapsed,  but  the 
majority  are  more  or  less  filled  with  serum,  leucocytes  and  epithelial  cells 
with  varying  degree  of  fatty  degeneration  according  to  the  duration  of 
the  disease.  The  local  effects  of  this  inflammation  are  similar  to  those 
of  croupous  pneumonia,  except  that  the  products,  of  catarrhal  pneu- 
monia contain  much  less  fibrin  and  fewer  red  corpuscles.  The  walls  of 
the  bronchioles  are  thickened  and  infiltrated  with  round  cells,  and  their 
epithelium  is  largely  exfoliated.  Their  calibre  is  in  some  places  con- 
tracted, in  others  dilated.  The  small  tubes  are  always  blocked  with 
catarrhal  secretion.  There  is  also  usually  present  more  or  less  peri- 
bronchitis.    The  alveolar  walls  are  congested. 

The  alveoli  adjacent  to  these  areas  of  consolidation  may  be  emphy- 
sematous and  are  often  the  seat  of  congestion  and  oedema.  The  pleura 
over  them  may  be  inflamed.  The  pulmonary  lymphatic  glands  are  com- 
monly enlarged.  Catarrhal  pneumonia  terminates  in  resolution,  suppura- 
tion, gangrene,  or  in  chronic  fibroid  induration,  or  the  products  may  un- 
dergo caseous  or  tubercular  degeneration. 

Etiology. — Lobular  pneumonia  is  most  common  in  infancy  before 
the  third  year,  and  in  advanced  age.  Bad  sanitary  conditions,  poor  food 
and  shelter,  and  debility  are  predisposing  factors.  It  is  always  second- 
ary to  affections  of  the  smaller  bronchi,  and  hence  arises  from  exposure 
to  the  exciting  causes  of  bronchitis.  It  is  apt  to  follow  influenza  and 
the  bronchitis  which  complicates  contagious  diseases,  especially  measles 
and  whooping-cough. 

Symptomatology. — The  essential  symptoms  are  rapidity  of  the  pulse 
and  of  respiration,  usually  with  high  temperature  and  troublesome  cough 
and  emaciation,  occurring  in  the  course  of  a  bronchitis. 

The  pulse,  at  first  strong,  frequently  becomes  feeble  and  compressible 
and  runs  up  to  from  140  to  160  per  minute,  and  the  respirations  from 
60  to  80.  The  temperature  gradually  rises  with  irregular  exacerbations 
and  remissions  to  104°  or  105°  F.,  and  in  fatal  acute  cases  may  go  two  or 
three  degrees  higher.  The  cough  loses  its  bronchial  character  and  be- 
comes hacking  and  painful,  and  is  followed  by  but  little  expectoration 
which  may  be  streaked  with  blood. 

The  most  important  signs  are  deficient  respiratory  movements,  slight 


LOBULAR  PNEUMONIA.  125 

and  occasionally  "patchy"  dulness,  with  deficient  vesicular  murmur  and, 
on  forced  inspiration,  numerous  poorly  defined  mucous  clicks.  When 
only  a  limited  number  of  lobules  are  affected,  a  diagnosis  cannot  be  ac- 
curately made;  but  if  several  lobules  are  involved,  the  signs  become 
quite  distinct. 

By  inspection  we  shall  usually  observe  rapid  but  imperfect  res- 
piratory movements,  with  very  slight  expansion  of  the  ribs  during 
inspiration,  but  considerable  elevation  of  the  chest  walls,  espe- 
cially at  the  upper  part ;  and  at  the  same  time  falling  in  of  the  soft 
parts  of  the  chest  and  retraction  of  the  lower  ribs,  as  in  pulmonary 
emphysema.  The  inspiration  is  often  shortened  and  the  expiration 
prolonged. 

When  several  inflamed  nodules  exist,  especially  if  they  are  located 
near  the  surface  of  the  lung,  palpation  will  discover  exaggerated  vocal 
fremitus. 

Upon  percussion,  dulness  will  be  found,  varying  in  degree  with  the 
amount  of  consolidation.  This  is  nearly  always  limited  to  the  inferior 
and  posterior  portions  of  the  chest,  and  usually  occurs  on  both  sides; 
but  the  disease  may  be  confined  to  one  lung  or  to  the  upper  lobes  of 
the  lungs. 

By  auscultation  more  or  less  broncho-vesicular  or  bronchial  respira- 
tion with  exaggerated  vocal  resonance  and  moist  high-pitched  rales  will 
usually  be  found  over  the  lower  part  of  the  lungs.  Likewise,  over  the 
upper  and  anterior  portions  of  the  chest  we  ordinarily  find  the  signs  of 
pulmonary  emphysema,  viz.,  vesiculotympanitic  resonance,  with  a  pro- 
longed and  low-pitched  expiratory  murmur. 

After  protracted  or  repeated  colds,  the  occurrence  of  a  feeble  vesicu- 
lar murmur,  with  several  illy  defined  mucous  clicks  on  forced  inspira- 
tion, should  cause  us  to  suspect  lobular  pneumonia.  The  mucous  clicks 
in  these  cases  are  due  to  retention  of  the  catarrhal  products  in  the  air 
cells. 

High-pitched  bronchial  rales  are  also  significant  of  consolidation. 
In  children,  some  of  the  alveoli  are  often  completely  choked,  so  that 
few  rales  are  produced.  In  adults,  the  inflammatory  products  are  more 
fluid,  and  consequently  rales  are  more  abundant. 

Diagnosis. — The  diagnosis  of  lobular  pneumonia  is  very  difficult,  un- 
less a  considerable  number  of  lobules  are  affected.  Even  then,  the  disease 
cannot  always  be  detected  by  the  physical  signs  alone,  but,  as  in  some 
cases  in  other  pulmonary  affections,  the  history  and  symptoms  must  be 
weighed  with  the  signs,  before  a  positive  opinion  can  be  formed.  For 
example,  in  a  child  suffering  from  bronchitis,  if  the  respiration  sud- 
denly becomes  accelerated,  the  temperature  elevated,  and  the  cough, 
which  may  previously  have  been  loose  and  easy,  becomes  dry,  hacking, 
and  painful,  we  have  good  reason  to  think  that  the  vesicular  portion  of 
the  lung  has  become  involved  in  the  inflammatory  process.     If,  in  addi- 


126  PULMONARY  DISEASES. 

tion  to  these  symptoms,  the  signs  of  consolidation  which  have  just  been 
enumerated  are  present,  the  diagnosis  may  be  considered  certain. 

The  distinctive  features  between  capillary  bronchitis  and  lobular 
pneumonia  may  be  found  under  the  differential  diagnosis  of  capillary 
bronchitis. 

Lobular  pneumonia  is  often  preceded  and  accompanied  by  collapse 
or  atelectasis  of  many  of  the  air  vesicles ;  for  this  reason  the  signs  of 
the  two  diseases  are  usually  considered  identical.  If  any  considerable 
amount  of  tissue  is  involved,  and  the  two  conditions  are  not  combined, 
a  differential  diagnosis  can  be  made  by  attention  to  the  following  symp- 
toms and  signs: 

Lobular  pneumonia.  Pulmonary  collapse. 

Symptoms. 
Temperature     suddenly     increased  ;  The  elevation  of   temperature,  and 

cough  becomes  dry  and  paroxysmal.  the  cough,  which  are  incidental  to  the 

associated    bronchitis,  are    not    mate- 
rially affected   by  collapse   of  the  air 
vesicles. 
Inspection. 
Falling  in  of  the  lower  portions  of  The  inverted  action  of  the  inferior 

the  chest,  which  may  have  been  noticed  ribs  is  increased  in  proportion  to  the 
in  bronchitis,  partially  disappears.  extent  of  atelectasis. 

Palpation. 

Vocal  fremitus  is  increased.  The  vocal  fremitus  is  not  likely  to 

be  increased,  but,  on  the  contrary,  it 
may  be  diminished. 

Percussion. 
Uniform  dulness,  or  distinct  patches  The  dulness  is  not  so  distinct,  and 

of  dulness,  usually  marked  over  the  there  is  occasionally  vesiculo-tym pa- 
lower  portions  of  the  chest.  nitic  resonance. 

The  dulness  usually  occurs  first  at 
the  border  of  the  left  lung,  where  it 
overlaps  the  heart ;  and  shortly  after- 
ward at  the  base  of  the  lungs.  From 
the  latter  position  it  has  a  tendency  to 
spread  upward  in  an  elongated,  some- 
what pyramidal  form  along  the  lines 
of  the  intervertebral  grooves,  in  which 
position  it  may  reach  as  high  as  the 
apex  of  the  lung. 

Auscultation. 

The    respiratory    sounds    generally  The     respiratory     sounds     usually 

harsh  or  broncho-vesicular  in  quality.  feeble.    The  rales  of  bronchitis  are  less 

never  wholly  tubular.      The  mucous  likely  to  be   present  than  in  lobular 

rales  of  bronchitis  usually  heard  over  pneumonia,  and  are  seldom  heard  over 

the    entire  chest ;    but,   in   many   in-  the  collapsed  lobules.    Sometimes  deep 

stances,  finer  moist  rales  are  obtained.  inspirations  may  bring  out  a  few  crep- 


LOBULAR  PNEUMONIA.  127 

limited  to  a  small  space  immediately        itant  rales,  which  are  heard  with  three 
over  the  inflamed  lobules.     When  the        or  four  inspiratory  acts,  and  then  dis- 
finer  bronchi  are  dilated,  as  sometimes        appear, 
happens  in  this  disease,  the  rales  be- 
come coarse  and  somewhat  metallic  if 
the  dilatations  are  surrounded  by  con- 
solidated lung. 

The  differential  diagnosis  between  lobular  pneumonia  and  lobar 
pneumonia  appears  below : 

Lobular  pneumonia.  Lobar  pneumonia. 

Symjitoms. 
Begins  with  a  bronchitis.  Begins  with  chill. 

No  chill.  Pain  in  the  side. 

No  crisis.  Terminal  crisis. 

Signs. 
Often  over  both  lungs  but  in  small,  Usually  confined  to  one  side  and  to 

scattered  areas.  one  large  area. 

Dulness  not  marked.  Dulness  marked. 

Mucous  with  smaller  rales.  Crepitant  and  subcrepitant  rales. 

Broncho-vesicular  voice  and  breath-  Bronchial  voice  and  breathing, 

ing. 

The  following  is  the  differential  diagnosis  between  lobular  pneu- 
monia and  acute  tubercular  phthisis: 

Lobular  pneumonia.  Acute  tubercular  phthisis. 

Symptoms. 
In  children  and  the  aged.  In  young  adults. 

Initial  bronchitis.  Initial  pyrexia  precedes  the  physical 

signs. 
Haemoptysis  not  common.  Haemoptysis  common. 

Emaciation    and    exhaustion    very  Emaciation  less  rapid, 

rapid. 

Signs. 
Most  marked  in  lower  and  posterior  Most  marked  at  apex, 

parts. 
No  tubercle  bacilli.  Sputum  sometimes  contains  tubercle 

bacilli. 

Prognosis. — This  disease  may  terminate  fatally  within  two  or  three 
days,  or  may  extend  over  many  weeks  or  months,  ending  in  resolution 
and  recovery,  or  in  purulent  infiltration,  or  in  cheesy  or  tubercular  de- 
generation and  death:  or  the  inflammation  may  cause  extensive  new 
connective-tissue  formation  in  the  interalveolar  septa  and  about  the 
bronchial  tubes,  eventuating  in  fibroid  phthisis,  which  may  extend  over 
several  years.  ' 

The  disease  is  most  fatal  in  infants,  especially  when  following  whoop- 
ing-cough or  measles,  and  in  aged  or  greatly  debilitated  subjects.  Death 
results  in  from  30  to  40  per  cent  of  all  cases,  some  authors  placing  the 
mortality  even  higher.     Among  the  grave  symptoms  are:  extension  of 


128  PULMONARY  DISEASES. 

the  bronchitis  and  increasing  cyanosis;  irregularity  of  the  respirations 
and  inefficient,  feeble  cough  with  cessation  of  expectoration ;  a  rapid, 
feeble  pulse;  temperature  exceeding  104°  F.,  and  stupor  or  convulsions  in 
the  later  stages  of  the  disease. 

Treatment. — Lobular  pneumonia  is  nearly  always  a  secondary  affec- 
tion, due  to  extension  of  the  inflammatory  process  from  the  bronchial 
mucous  membrane  in  consequence  of  debility.  Bearing  this  in  mind, 
we  avoid  all  depressing  remedies  such  as  antimony,  aconite,  or  veratrum 
viride,  and  very  early  commence  the  use  of  stimulants. 

Quinine  is  the  best  remedy  to  moderate  the  fever.  Alcohol  should 
be  given  according  to  the  amount  of  depression.  The  rule  is  to  give  as 
much  as  can  be  borne  without  causing  head  symptoms.  Ammonium 
carbonate  or  ammonium  iodide  are  very  useful,  not  only  for  the  stimu- 
lation which  they  afford,  but  also  for  their  beneficial  effects  in  removing 
the  products  of  inflammation. 

Sedative  inhalations  are  useful  early  in  the  attack,  and  at  a  later 
period  stimulant  inhalations  and  counter-irritation  are  beneficial.  If 
the  patient  emaciate,  calcium  chloride,  tincture  of  iron,  and  cod-liver 
oil  are  indicated.  A  change  of  climate  is  advisable  if  recovery  does  not 
take  place  within  eight  or  ten  weeks. 


PECULIAR    FORMS    OF    PNEUMONIA. 

Several  somewhat  peculiar  forms  of  pneumonia  merit  passing  consid- 
eration, though  they  are  not  distinct  varieties  of  the  disease.  These 
are:  interstitial  pneumonia,  typhoid  pneumonia,  bilious  pneumonia, 
pneumonia  due  to  cardiac  disease,  and  pneumonia  from  Bright's  disease. 

The  treatment  of  these  forms  is  essentially  the  same  as  that  for 
the  diseases  with  which  they  are  associated,  combined,  as  occasion  may 
seem  to  require,  with  the  resolvents  and  expectorants  indicated  in  lobu- 
lar pneumonia. 

Chronic  or  interstitial  pneumonia  (sometimes  termed  catarrhal 
pneumonia)  will  be  described  under  the  head  of  Fibroid  Phthisis. 

Typhoid  pneumonia  is  a  term  that  may  be  applied  to  a  certain 
complication.  If  pneumonia  complicates  typhoid  fever,  or  vice  versa, 
the  symptoms  of  the  one  disease  are  associated  with  and  somewhat 
modified  by  those  of  the  other,  and  the  resulting  prostration  is  marked. 
The  secondary  pneumonia  is  here  indicated  by  increased  rapidity  of  the 
pulse  and  respiration,  with  signs  of  consolidation.  Cough  and  sanguino- 
lent  sputum  are  rarely  present. 

The  expression  typhoid  pneumonia  also  refers  to  pneumonia  of  a 
sthenic  and  usually  fatal  form,  frequently  epidemic  among  soldiers  and 
others  subject  to  unhealthful  sanitary  conditions.  The  chief  features 
are  extreme  exhaustion  and  constant  tendency  to  collapse,  although  the 


ABSCESS  OF  THE  LUNQ.  129 

local  pulmonary  signs  may  be  but  slight.  Symptoms  like  those  of  sep- 
ticaemia may  be  prolonged  for  months. 

Peculiarly  viscid  subcrepitant  rales  may  be  heard,  few  in  number 
and  found  irregularly  at  the  base  or  apex  of  the  lung. 

Bilious  pneumonia,  which  is  most  common  in  malarial  districts,  is, 
in  addition  to  the  symptoms  of  typical  croupous  pneumonia,  characterized 
by  jaundice,  greenish,  viscid,  and  inodorous  stools,  with  other  evidences 
of  hepatic  and  gastric  disorder,  and  a  fever  record  intermittent  in  type, 
the  febrile  exacerbations  being  sometimes  preceded  during  the  early 
part  of  the  day  by  chilly  sensations  and  coolness  of  the  ends  of  the  nose, 
fingers,  and  toes. 

Pneumonia  arising  from  disease  of  the  heart,  especially  from 
marked  mitral  lesions,  presents  many  features  similar  to  those  of  lobular 
pneumonia.  The  invasion  is  usually  slow,  seldom  preceded  by  rigors. 
There  is  a  chronic  cough,  with  expectoration  which  seldom  becomes 
rusty  or  tenacious.  The  signs  may  appear  in  scattered  patches,  which 
change  their  seat  from  day  to  day,  but  are  usually  found  over  the  lower 
lobes  of  both  lungs. 

There  is  some  exaggeration  of  the  vocal  fremitus,  slight  dulness,  and 
blowing  though  not  strictly  bronchial  respiration,  with  exaggerated 
vocal  resonance. 

Pneumonia  from  Bright's  disease  may  not  differ  materially  from 
ordinary  acute  pneumonia,  or  it  may  begin  in  collapse  of  portions  of 
the  vesicular  structure,  and  present  characteristics  similar  to  those  of 
lobular  pneumonia. 

ABSCESS  OF  THE  LUNG. 

Abscess  of  the  lung  consists  of  a  circumscribed  collection  of  pus 
within  the  pulmonary  parenchyma.  It  is  usually  characterized  by  pain, 
rigors  and  fever,  and  later  by  expectoration  of  a  small  amount  of  blood 
immediately  followed  by  a  large  quantity  of  pus,  which  escapes  within  a 
few  hours.  These  abscesses  are  rare  excepting  when  secondary  to  tuber- 
culosis, pygemia,  or  embolism,  in  which  cases  they  are  usually  multiple 
and  must  be  considered  as  incidental  to  the  primary  disease.  They  may 
also  result  from  the  entrance  of  foreign  bodies  into  the  air  passages, 
obstruction  of  the  bronchi  by  tumors,  or  from  suppuration  of  the  bron- 
chial glands ;  also  from  perforating  abscesses  from  below  the  diaphragm 
or  from  the  mediastinum.  The  pulmonary  abscesses  which  chiefly 
interest  us  are  those  resulting  from  acute  pneumonia. 

Symptomatology. — The  abscess  usually  follows  within  a  few  days, 
upon  some  exposure,  and  occurs  during  the  acute  stage  of  the  inflamma- 
tion, being  preceded  by  the  chill  and  fever  of  acute  pulmonary  inflam- 
mation; but  sometimes  it  occurs  after  the  pneumonia  has  subsided. 
The  formation  of  pus  is  commonly  attended  by  rigors  which  are  followed 
9 


130  PULMONARY  DISEASES. 

by  hectic  fever.  Pain  is  usually  present  in  the  beginning.  There  are 
irregular  chills,  and  the  temperature  fluctuates  during  the  day  two  or 
three  degrees.  In  the  milder  cases,  though  the  pulse  is  rapid,  the 
pyrexia  is  not  pronounced,  and  spontaneous  opening  and  cure  may  be 
expected  in  the  course  of  a  few  weeks. 

Unless  the  patient  dies  of  exhaustion,  the  abscess  commonly  opens 
within  ten  to  twenty  days,  the  profuse  purulent  discharge  commonly 
being  preceded  by  a  few  drops  of  blood  or  bloody  pus.  Often  from  half 
a  pint  to  a  pint  of  yellowish  or  greenish,  though  occasionally  brownish, 
pus  is  expectorated  within  a  few  hours.  The  pus,  excepting  in  cases  of 
gangrene  or  where  it  has  been  long  retained,  is  not  particularly  offensive. 
Occasionally  the  abscess  ruptures  into  the  pericardium  or  pleura. 
The  sputum  commonly  contains  small  yellowish  or  dark-colored  bits  of 
lung  tissue  visible  to  the  naked  eye,  which  upon  microscopic  examina- 
tion are  found  to  contain  elastic  fibre. 

Tlie  signs  are:  dulness,  with  feebleness  or  absence  of  the  respiratory 
murmur  over  the  abscess,  combined  with  indistinct  rales  and  sometimes 
bronchial  breathing  in  the  lung  tissue  about  it,  and  after  escape  of  pus, 
for  a  short  time  the  signs  of  a  cavity. 

Diagnosis. — The  affection  is  liable  to  be  mistaken  for  bronchitis, 
pneumonia,  or  acute  or  chronic  pleurisy.  The  most  important  features 
in  the  diagnosis  are:  the  symptoms  of  acute  pneumonia  followed  by 
irregular  chills  and  fever ;  dulness  more  or  less  circumscribed,  but  apt 
to  be  more  distinct  than  that  of  pneumonia  and  less  than  that  of  pleu- 
risy ;  atypic  respiratory  and  vocal  signs,  and  finally  sudden  expectoration 
of  a  large  quantity  of  pus  in  which  may  be  found  elastic  fibre. 

Bronchitis  is  distinguished  by  absence  of  the  initial  chill  and  subse- 
quent rigors,  slight  fever,  absence  of  dulness  on  percussion,  and  the 
presence  of  bilateral  rales;  and  by  the  character  of  the  expectoration. 

Pneumonia  yields  very  similar  symptoms  and  signs,  but  seldom 
causes  the  irregular  chills  and  fever.  In  pneumonia  the  dulness  may 
be  less  or  more  marked  according  to  the  size  of  the  abscess  and  the 
amount  of  healthy  lung  tissue  between  it  and  the  surface;  but  eventually 
the  dulness  in  case  of  abscess  becomes  more  distinctly  circumscribed. 
In  pneumonia  distinct  crepitant  and  subcrepitant  rales  or  bronchial 
breathing  are  practically  always  present,  while  over  a  pulmonary  abscess 
there  may  be  a  feeble  normal  murmur  or  absence  of  respiratory  sounds, 
or  there  may  be  irregular  bronchial  rales,  which  are  likely  to  be  most 
distinct  in  a  zone  surrounding  the  abscess. 

Acute  'pleurisy  may  be  differentiated  by  the  presence  of  friction 
sounds  and  fremitus,  but  absence  of  vocal  fremitus.  In  it  there  is  more 
decided  dulness,  and  less  distinct  respiratory  and  vocal  signs  than  in 
abscess,  and  there  is  no  hectic  fever.  When  there  is  much  effusion, 
change  of  the  level  of  flatness  by  changing  the  patient's  position  and 
displacement  of  the  heart  differentiate  it  from  abscess. 

Chronic  pleurisy,   or  empyema,  when  general,  can  be  easily  distin- 


ABSCESS  OF  THE  LUNG.  131 

guished  from  abscess  of  the  lung,  but  when  circumscribed  the  signs  are 
not  characteristic  until  a  microscopic  examination  of  the  pus  reveals 
elastic  fibre  in  the  case  of  abscess  but  none  in  empyema. 

Prognosis. — The  affection  may  prove  fatal  within  two  or  three 
weeks  or  may  be  prolonged  for  months.  If  the  abscess  opens  spontane- 
ously it  will  usually  do  so  within  three  weeks.  Many  cases  die  of  ex- 
haustion, some  by  infection  of  other  parts,  and  still  others  by  repeated 
pneumonias  developing  about  the  purulent  cavity;  yet  a  considerable 
number  recover.  The  cases  caused  by  pyaemia,  gangrene,  tuberculosis, 
embolism,  are  necessarily  grave. 

Treatment. — Commonly  the  profession  favors  expectant  treatment 
with  tonics  and  ample  nourishment,  but  when  the  abscess  can  be  located, 
especially  if  near  the  chest  wall,  the  question  of  surgical  interference 
must  be  considered.  Knowing  the  danger  of  the  operation  and  remem- 
bering that  many  cases  recover  spontaneously,  I  believe  that  the  greatest 
good  to  by  far  the  greatest  number  will  be  obtained  in  most  cases  by 
pursuing  the  expectant  plan  for  at  least  three  or  four  weeks;  but  when 
we  have  reason  to  believe  that  there  is  a  single  abscess  near  the  surface 
of  the  lung,  when  sufficient  time  has  been  given  for  spontaneous  open- 
ing, and  when  progressive  emaciation  and  hectic  fever  indicate  the 
retention  of  pus,  it  is  safer  for  the  patient  to  open  the  abscess  from 
without. 

Aspiration  alone  or  combined  with  washing  out  the  cavity  with  a 
disinfecting  solution  will  prove  curative  in  a  considerable  number  of 
cases  and  should  be  tried  first,  but  if  it  fails  the  surgeon,  with  antiseptic 
precautions,  should  cut  down  and  resect  a  portion  of  one  or  more  ribs. 
If  the  lung  is  found  not  adherent  to  the  pleura  it  should  be  drawn  up 
and  stitched  to  the  external  pleura,  where  it  will  become  firmly  attached 
within  a  few  hours.  Then  (or  at  once  if  the  two  surfaces  of  the  pleura 
are  adherent)  an  opening  should  be  made  through  the  lung  tissue  to  the 
cavity  by  means  of  the  therm o-cautery,  and  a  large-sized  drainage  tube 
introduced.  Strong's  tubes  spoken  of  in  treating  of  empyema  (Fig.  23) 
are  well  adapted  for  this  purpose.  The  cavity  should  subsequently  be 
managed  as  those  of  other  abscesses,  and  the  patient  sustained  by  tonics 
and  nutritious  diet. 


CHAPTER  IX. 

PULMONARY  DISEASES.— Continued. 

PULMONARY   HYPEREMIA. 

Pulmonary  hyperemia  signifies  an  excess  of  blood  in  the  pulmonary 
vessels.  It  may  be  general  or  local,  active  or  passive.  It  possesses  no 
distinctive  physical  signs  unless  associated  with  pulmonary  oedema  or 
bronchial  hemorrhage. 

Anatomical  and  Pathological  Characteristics. — Lungs  which 
are  the  seat  of  active  hyperaemia  are  redder,  slightly  heavier,  and  less 
crepitant  than  normal.  An  unusual  amount  of  arterial  blood  escapes  on 
section.  The  capillaries  are  distended,  the  alveolar  epithelium  is  swollen, 
and  the  bronchial  mucous  membrane  may  be  injected.  (Edema  may  ac- 
company a  local  active  hyperemia.  Active  hyperaemia  may  speedily  dis- 
appear or  it  may  terminate  in  inflammation. 

In  passive  hyperemia  or  congestion,  the  lungs  are  of  a  dark  red  or 
purple  color,  the  dependent  parts  showing  marked  post-mortem  staining 
of  a  darker  hue;  the  organs  are  heavier  and  less  crepitant  than  normal, 
and  the  flow  of  blood  on  section  is  copious  and  dark,  but  mixed  with  air. 
The  capillaries  are  engorged,  distended,  and  tortuous ;  the  air  sacs  con- 
tain serum  with  blood  corpuscles,  leucocytes,  and  epithelial  cells  more 
or  less  granular.  The  connective  tissue  is  usually  slightly  cedematous 
and  shows  small  extravasations.  In  severe  and  continued  congestion 
these  changes  are  exaggerated,  there  is  greater  thickening  of  the  alveo- 
lar walls,  engorgement  of  the  vessels,  oedema,  collapse  of  some  of  the 
air  sacs,  and  decrease  in  the  amount  of  air  in  the  lung,  which  is  of  dark 
red  color  dotted  with  lighter  points  of  extravasation,  partially  decolor- 
ized. The  fluid  from  the  cut  surface  is  more  watery.  This  condition 
is  termed  splenization.  Prolonged  obstruction  to  the  pulmonary  cir- 
culation due  to  mitral  disease  results  in  brown  induration.  Here, 
in  addition  to  the  capillary  engorgement  and  alveolar  changes,  there  is 
extensive  pigmentation  of  the  lung  along  the  lymphatics  and  vessels 
and  about  the  connective-tissue  cells,  from  deposit  of  brown  granules  of 
hsematin  derived  from  the  degenerate  red  corpuscles  and  carried  thither 
by  the  leucocytes.  There  is  also  marked  connective-tissue  hyperplasia. 
The  lung  is  consequently  dark  brown  in  color  with  yellowish  and  red- 
dish patches  due  to  extravasations  in  various  stages  of  decoloration.  It 
is  larger,  heavier,  firmer,  less  cedematous,  and  drier  than  a  splenoid  lung. 


PULMONARY  HYPEREMIA.  133 

Hypostatic  congestion  signifies  passive  hyperemia  of  dependent  parts, 
usually  bilateral  and  due  to  cardiac  weakness  in  those  long  confined  to 
bed  by  exhausting  diseases. 

Etiology. — Active  hypergemia  may  be  due  to  increased  cardiac  action 
from  violent  exercise,  medicinal  stimulation,  mental  excitement,  and  cer- 
tain neuroses,  or  to  local  irritation  from  inhalation  of  pungent  gases, 
foreign  bodies,  and  hot  or  cold  air;  or  to  diminution  of  inter-alveolar 
pressure  in  the  rarefied  atmosphere  of  high  altitudes  or  during  inspira- 
tory expansion  of  the  chest  with  obstructed  air  passages,  as  in  croup, 
oedema  glottidis,  and  tumors  of  the  larynx.  Lastly,  interference  with 
the  circulation  in  one  part  of  the  lung  may  cause  compensatory  or  col- 
lateral hypereemia  of  the  other  parts. 

Passive  pulmonary  hyperemia  is  due  either  to  inefficient  j^ropulsion 
of  the  blood  through  the  lung  from  weakness  or  inefficiency  of  the  right 
heart  or  to  obstruction  in  the  pulmonary  artery  or  to  interference  with 
the  outflow  of  blood  from  the  lung  owing  to  valvular  disease  or  weak- 
ness of  the  left  heart  or  pressure  on  the  pulmonary  veins. 

Symptomatology. — We  can  best  recognize  pulmonary  congestion 
by  considering  its  history  and  symptoms,  in  connection  with  the  physi- 
cal signs.  For  example,  if  a  patient  is  attacked  with  sudden  dyspnoea 
after  extreme  physical  exertion  or  exposure  to  the  influence  of  a  rarefied 
atmosphere,  as  in  high  altitudes,  pulmonary  congestion  should  be  sus- 
pected ;  and  if  the  dyspnoea  is  attended  with  a  profuse  watery  and  blood- 
stained expectoration  and  the  signs  of  oedema,  we  may  be  positive  of  our 
diagnosis. 

In  such  cases  percussion  reveals  slight  dulness  over  the  lower  por- 
tions of  the  chest. 

Auscultation  reveals  a  feeble  respiratory  murmur,  crepitant  rales, 
and  usually  an  abundance  of  large  and  small  mucous  rales. 

Accentuation  of  the  second  sound  of  the  heart,  at  the  pulmonai'y  orifice,  has 
been  considered  by  some  authors  diagnostic  of  pulmonary  congestion  ;  but  this 
sign  cannot  be  relied  on,  as  it  may  be  only  relative,  due  to  feebleness  of  the 
aortic  sound  ;  moreover,  this  accentuation  is  a  common  sign  in  cardiac  disease. 

In  the  congestion  of  the  lung  which  immediately  precedes  pneumonia, 
physical  examination  reveals  very  slight  dulness,  with  feebleness  of  the  respira- 
tory murmur  and,  possibly  here  and  there,  a  crepitant  or  subcrepitant  rale.  This 
condition,  however,  is  not  usually  included  under  the  head  of  pulmonary  con- 
gestion. 

Peognosis. — Active  pulmonary  hyperemia  may  cause  death  within  a 
few  hours  from  oedema  or  hemorrhage,  or  it  may  terminate  in  pneumonia. 
It  is  ordinarily  amenable  to  early  and  prompt  treatment.  Mild  cases 
are  usually  of  short  duration  and  recover  spontaneously.  Passive  hy- 
peremia is  more  serious,  but  the  prognosis  depends  largely  upon  the 
gravity  of  the  cause.  Chronic  cases  due  to  heart  disease  are  liable  to 
sudden  fatal  attacks  of  oedema. 


134  PULMONARY  DISEASES. 

Treatment. — When  the  congestion  comes  on  suddenly,  full  doses 
of  ergot  should  be  given.  Bleeding  will  be  found  useful  in  cases  of  ex- 
treme plethora.  Dry  or  wet  cupping  over  the  chest  is  sometimes  bene- 
ficial. A  blister  will  occasionally  prevent  the  supervention  of  inflamma- 
tion. If  the  heart  is  weak,  it  should  be  stimulated;  and  if  pulmonary 
oedema  coexist,  alcoholic  stimulants  should  be  given  freely  and  a  hydra- 
gogue  cathartic  may  be  administered. 


BROWN   INDURATION. 

The  symptoms  of  brown  induration  are  those  of  the  causative  initial 
disease,  with  cough  and  haemoptysis. 

The  principal  sign  is  dulness,  limited  mostly  to  the  second  intercos- 
tal space  near  the  sternum.  There  are  also  exaggerated  vocal  resonance, 
broncho-vesicular  or  bronchial  breathing,  bronchophony,  and  occasionally 
pectoriloquy. 

This  affection  may  be  differentiated  from  other  pulmonary  diseases 
by  the  position  of  the  dulness  and  the  presence  of  the  symptoms  and 
signs  of  mitral  disease. 

Treatment  will  aim  to  relieve  the  cardiac  affection.  Ammonium 
carbonate  and  chloride,  moderate  doses  of  digitalis  and  tincture  of  nux 
vomica,  are  especially  indicated,  and  counter-irritation  may  be  beneficial. 


PULMONARY   HEMORRHAGE. 

Pulmonary  hemorrhage  includes  hemorrhage  from  the  bronchi 
(bronchorrhagia)  and  from  the  parenchyma  of  the  lung  (pneumonor- 
rhagia).  The  chief  symptom  is  haemoptysis.  This  term,  used  loosely, 
in  a  broad  sense  denotes  spitting  of  blood,  whether  in  large  quantity  as 
from  the  rupture  of  an  aneurism  into  the  air  passages,  or  in  small 
amount,  merely  streaking  the  sputum  of  chronic  bronchitis,  or  as  found 
in  the  rusty  or  prune-juice  expectoration  of  pneumonia.  Properly,  it 
signifies  the  raising  of  more  or  less  pure  blood  from  vessels  bleeding 
into  the  larynx,  trachea,  bronchi,  or  alveolar  structure. 

Anatomical  and  Pathological  Characteristics. — The  appear- 
ance of  the  lung  after  pulmonary  hemorrhage  depends  upon  the  extent 
of  the  hemorrhage,  its  cause,  and  the  time  at  which  the  organ  is  in- 
spected. If  post-mortem  examination  is  made  soon  after  bronchial  hem- 
orrhage, the  lung  in  general  may  be  anaemic,  marked  by  isolated  bright 
red  spots  at  points  where  blood  has  gravitated  or  has  been  drawn  into 
superficial  alveoli.  On  section,  coagula  may  also  be  found  blocking  the 
bronchi.  If  these  collections  in  the  air  sacs  and  tubes  are  numerous  or 
large,  the  lung  to  that  extent  will  be  heavier,  less  crepitant,  and  less  apt 
to  collapse.     Its  cut  surface  will  show  red,  firm  patches  or  nodules  re- 


PULMONAR  Y  HEMORRHA  QE.  1 35 

sembling  infarcts,  from  which  sero-sanious  fluid  escapes.  The  bron- 
chial mucous  membrane  may  appear  almost  normal,  or  ecchymotic,  red, 
swollen  and  softened.  If  the  examination  be  made  long  after  deaths 
there  may  be  little  or  no  remaining  evidence  of  an  abnormal  condition, 
or  the  coagula  in  the  air  sacs  may  be  partially  decolorized.  The  hem- 
orrhage may  in  some  cases  give  rise  to  lobular  pneumonia. 

If  hemorrhage  has  come  from  an  abscess  or  tubercular  cavity,  an 
eroded  vessel  or  ruptured  aneurism  may  be  found  in  the  wall  of  the 
cavity  or  in  one  of  the  trabecular  traversing  its  space.  Brown  indura- 
tion of  the  lung  also  will  often  be  found,  with  the  evidence  of  hemor- 
rhage due  to  mitral  disease  of  long  standing. 

In  other  cases,  atheromatous,  fatty,  or  amyloid  degeneration  of  the 
vessels  may  mark  the  seat  of  parenchymatous  hemorrhage.  Rarely  sub- 
pleural  haematoma  and  haeniothorax  are  present. 

Etiology. — All  those  conditions  which  weaken  the  walls  of  the  pul- 
monary blood-vessels  predispose  to  haemoptysis.  They  include  tubercu- 
losis, abscess,  and  gangrene,  which  diminish  the  local  support  of  the  ves- 
sels; also  changes  in  the  vascular  walls,  such  as  atheromatous,  fatty,  or 
amyloid  degeneration,  and  atrophic  changes  incident  to  haemophilia,,  pur- 
pura, scorbutus,  and  the  infectious  diseases;  also  heart  disease  and  other 
conditions  which  produce  chronic  over-distention  of  the  pulmonary 
vessels.  The  usual  exciting  causes  are  muscular  exertion,  coughing, 
loud  speaking,  or  concussion  from  a  blow  or  fall.  Other  cases  occur  from 
penetrating  wounds,  but  in  quite  a  large  percentage  of  cases,  no  exciting 
cause  can  be  discovered. 

Symptomatology. — The  chief  symptom  is  expectoration,  usually 
of  arterial  blood,  more  or  less  frothy;  perhaps  immediately  preceded  by 
a  sensation  as  of  warm  fluid  trickling  beneath  the  sternum.  This  may 
follow  severe  cough  or  strain  and  without  premonition,  or  may  be  pre- 
ceded by  coldness  of  the  extremities,  congestion  of  the  face,  headache, 
dizziness,  thoracic  oppression,  or  palpitation. 

Haemoptysis  may  be  followed  by  nausea  and  vomiting,  and  is  apt  to 
occasion  considerable  mental  shock.  Large  and  small  bronchial  rales 
are  present  in  most  cases  during  active  hemorrhage,  and  may  remain  for 
several  hours.  Feeble  respiration  is  sometimes  noticeable  and  dulness 
may  be  present,  though  frequently  no  signs  whatever  can  be  detected  by 
the  most  careful  examination. 

Diagnosis. — Haemoptysis  may  be  mistaken  for  haematemesis,  epi- 
staxis,  or  hemorrhage  from  the  gums  or  the  pharynx.  The  distinctive 
features  are  as  follows : 

HAEMOPTYSIS.  HLEMATEMESIS. 

History. 

Usually  history  of    pulmonary    or  Usually  gastric  or  hepatic  disease, 

heart  disease,  especially  phthisis. 


136  PULMONARY  DISEASES. 

HEMOPTYSIS.  H.CMATEMESIS. 

Symptoms. 

A  preceding  thoracic  oppression  or  A  preceding  sense  of  pain  or  fulness, 

premonitory  sensation  of  trickling  fluid 
beneath  the  sternum. 

Blood  expelled  primarily  by  cough.  Blood  expelled  primarily  by  vomit- 

Vomiting  secondary  if  present.  ing. 

Subsequent    cough    and    bronchial  Chest  signs  negative, 

rales. 

Character  of  blood. 

Usually  bright  red  and  frothy  from  Usually  dark  clotted  or  grumous ; 

admixture  of  air.  may  be  mixed  with  food. 

Alkaline  reaction.  Acid  reaction. 

In  epistazis  inspection  of  the  nares  and  post-nares  with  reflected  light 
reveals  the  course  of  the  blood  and  perhaps  its  origin.  Hemorrhage  from 
the  gums  or  the  pharynx  can  generally  be  readily  recognized  by  careful 
inspection. 

Prognosis. — Pulmonary  hemorrhage,  though  rarely  immediately 
fatal,  is  in  most  oases  indicative  of  phthisis.  A  single  hemorrhage  may 
amount  to  a  pint  or  more,  and  continue  from  a  few  minutes  to  several 
hours.  As  a  rule  it  is  followed  by  others.  In  most  instances  it  is  fol- 
lowed by  the  occasional  expectoration  of  a  small  amount  of  clotted 
blood  for  two  or  three  days.  Frequent  recurrence,  or  severe  hemorrhage 
if  not  fatal,  results  in  anaemia  or  may  cause  lobular  pneumonia.  When 
occurring  in  phthisis,  haemoptysis  seems  occasionally  to  check  its  course 
temporarily;  commonly  the  patient  expresses  a  feeling  of  increased 
well  being.  Rarely,  it  is  followed  by  a  more  rapid  progress  of  the  dis- 
ease. It  is  a  fatal  symptom  if  due  to  ruptured  aneurism,  and  serious  if 
complicating  pulmonary  abscesses,  gangrene,  malignant  growths,  or 
when  accompanying  the  infectious  diseases  or  grave  dyscrasia  and  occa- 
sionally when  resulting  from  heart  disease. 

Death  may  occur  from  depleted  circulation,  asphyxia,  or  from  grad- 
ual exhaustion  due  to  anaemia  or  to  secondary  pneumonia. 

Treatment. — The  patient  should  be  kept  perfectly  quiet  until  all 
bleeding  ceases. 

The  most  efficient  remedies  for  checking  the  hemorrhage  are  full 
doses  of  ergot,  gallic  acid,  or  lead  acetate  and  opium. 

The  hemorrhage  may  sometimes  be  checked  by  the  inhalation  of  a 
spray  from  a  weak  solution  of  liquor  ferri  subsulphatis — tT[x.,  aqua  ad  3  i. 

In  estimating  the  value  of  any  remedy  for  this  purpose  it  must  not 
be  forgotten  that  the  bleeding  will  usually  cease  in  a  short  time  wheth- 
er remedies  are  used  or  not.  Loomis  relies  more  upon  aconite  and 
opium  than  upon  styptics.  If  ice  is  applied  to  the  chest,  it  should  be 
done  with  great  care,  as  it  seems  to  favor  the  supervention  of  broncho- 
pneumonia after  hemorrhage  (Loomis'  Practical  Medicine,  p.  95). 


PULMONARY  APOPLEXY.  137 


PULMONARY   APOPLEXY. 

Synonyms. —  Diffuse  pulmonary  hemorrhage,  pneunionorrhagia, 
hemorrhagic  infarctus. 

Pulmonary  apoplexy  is  a  rare  affection,  consisting  of  extravasation  of 
blood  into  the  lung  tissue.     It  usually  occurs  in  the  lower  lobes. 

Since  apoplexy  etymologically  refers  to  loss  of  consciousness  inci- 
dent to  rupture  of  a  cerebral  artery,  this  term  is  not  aptly  applied  to  in- 
terstitial pulmonary  hemorrhage;  usage,  however,  has  authorized  it. 

Anatomical  and  Pathological  Chaeacteeistics. — Pulmonary 
apoplexy  consists  of  an  escape  of  blood  into  the  parenchyma  of  the  lung 
from  a  ruptured  vessel,  attended  by  more  or  less  laceration  and  infiltra- 
tion of  the  tissues,  according  to  the  size  of  the  damaged  vessel,  the  cause 
of  the  injury,  and  the  condition  of  the  lung. 

The  lung  is  relatively  heavier  and  firmer  than  normal,  and  contains 
no  air  in  the  affected  portion.  Not  infrequently  several  extravasations 
exist  from  the  bursting  of  vessels  in  different  parts  of  the  organ. 

The  resulting  clots  or  hemorrhagic  infarcts,  as  distinguished  from 
embolic  infarcts,  are  of  pyramidal  form,  the  bases  of  the  pyramids  ap- 
pearing superficially  beneath  the  pleura  as  dark  red  or  almost  black 
patches,  the  sides  corresponding  to  the  inter-iobular  boundaries  ;  occa- 
sionally the  pleura  is  also  torn,  and  blood  escapes  into  the  pleural  sac. 
The  cut  surface  is  firm  but  moist  and  of  uniformly  dark  color  in  the 
early  stages,  but  later  the  clots  gradually  become  decolorized.  Hemor- 
rhagic infarcts  somewhat  resemble  true  embolic  infarcts,  but  are  usually 
larger  and  more  sharply  defined.  Apoplectic  extravasation  may  cause 
death  immediately  or  from  subsequent  suppuration  or  gangrene.  It  may 
end  in  resolution,  complete  or  accompanied  by  cicatricial  contraction,  or 
may  undergo  caseation,  calcification  and  encapsulation. 

Etiology. — Hemorrhagic  infarctus  in  the  lung  is  usually  the  result 
of  pulmonary  hyperemia  acting  upon  vessels  already  the  seat  of  degen- 
erative changes.  Such  changes  frequently  give  rise  to  multiple  aneu- 
risms which  give  way  on  sudden  or  prolonged  intra-vascular  pressure. 
A  severe  blow  or  a  wound  of  external  origin  may  cause  diffuse  hemor- 
rhagic infiltration  or  it  may  result  from  erosion  of  a  vessel  by  ulceration. 

Symptomatology. — This  affection  is  usually,  though  not  invariably, 
attended  with  dyspnoea  and  hsemoptysis,  the  expectorated  blood  con- 
taining small  dark  clots. 

The  principal  signs  are :  more  or  less  dulness,  feeble  or  bronchial 
respiration,  and  mucous  rales. 

When  the  coagula  are  few  in  number,  and  small  or  deep-seated,  per- 
cussion yields  no  signs;  but  if  they  are  numerous,  or  lie  superficially, 
dulness  will  be  more  or  less  marked. 


138  PULMONARY  DISEASES. 

Upon  auscultation,  mucous,  subcrepitant,  and  possibly  well-marked 
crepitant  rales  will  be  detected  in  and  about  the  extravasations,  until 
coagulation  of  blood  has  taken  place.  Afterward,  respiration  will  be 
feeble  or  suppressed  over  the  extravasations;  or  bronchial  breathing 
and  exaggerated  vocal  resonance  may  be  obtained,  if  a  large  clot  lies  in 
apposition  with  a  bronchial  tube. 

Diagnosis. — The  diagnosis  of  pulmonary  apoplexy  must  be  based 
upon  the  history  and  the  character  of  the  sputa,  in  connection  with 
the  signs  found  upon  percussion  and  auscultation.  It  is  not  likely  to 
be  mistaken  for  any  other  disease  except  pneumonia,  from  which  it  can 
easily  be  distinguished  by  the  history  and  by  the  expectoration. 

Treatment. — The  treatment  should  be  mainly  directed  to  the  cause 
of  the  hemorrhage.  Removal  of  the  blood-clot  is  probably  hastened  by 
the  administration  of  potassium  iodide,  or  liquor  potassse  and  other 
alkalies.  Counter-irritation  is  useful  in  some  cases  a  few  days  after  the 
accident.  Quiet  must  be  maintained  for  two  or  three  weeks  to  prevent 
a  recurrence  of  the  attack.  If  pneumonia  or  pleurisy  supervene,  they 
should  be  treated  essentially  the  same  as  when  they  occur  alone. 

PULMONARY  THROMBOSIS  AND   EMBOLISM. 

Pulmonary  thrombosis  consists  of  the  gradual  obstruction  of  a 
blood-vessel  in  the  lung  by  a  coagulum  formed  in  situ.  It  occurs  in 
the  pulmonary  artery  or  some  of  its  branches,  as  a  result  of  local  non- 
inflammatory vascular  degeneration  or  of  inflammation  in  the  surround- 
ing lung  tissue. 

Pulmonary  embolism  consists  of  a  sudden  obstruction  of  a  vessel 
by  a  foreign  body,  usually  a  fragment  of  a  cardiac  valvular  vegetation 
or  of  a  thrombus  in  some  of  the  systemic  veins.  Embolism  may  occur 
in  the  pulmonary  artery  by  lodgment  of  a  thrombotic  fragment  from 
the  veins  of  the  abdomen  or  lower  extremities  or  it  may  occur  in  the 
bronchial  arteries  by  an  obstruent  brought  from  the  mitral  or  aortic 
valves. 

Anatomical  and  Pathological  Characteristics. — Pulmonary 
embolic  infarcts  are  usually  multiple  and  occur  near  the  surface  of  the 
lung,  especially  in  the  posterior  part  of  the  lower  lobe.  In  form  and 
gross  appearance  they  resemble  hemorrhagic  infarcts,  but  they  depend 
upon  obstruction  of  a  blood-vessel,  instead  of  rupture.  At  the  apex  of 
this  infarct,  usually  at  the  bifurcation  of  an  artery,  an  embolus  is  gen- 
erally to  be  found  about  which  a  secondary  thrombus  has  formed.  The 
conical  form  of  the  infarct  corresponds  to  the  distribution  of  the  branches 
of  the  occluded  vessel  on  the  distal  side  of  the  obstruction.  These  being 
no  longer  supplied  with  blood  by  the  main  vessel,  become  engorged,  ac- 
cording to  Cohnheim,  by  regurgitation  of  blood  from  the  veins,  but  ac- 
cording to  Litten  this  is  due  to  a  small  amount  of  arterial  blood  still 


PULMONARY  COLLAPSE.  139 

supplied  to  the  part  by  arterioles,  which,  however,  are  not  sufficient  in 
size  and  number  to  afford  adequate  collateral  circulation.  The  changes 
in  the  part,  consequent  upon  engorgement  and  stasis,  are :  migration  of 
leucocytes,  deterioration  of  the  tunica  intima,  diapedesis  of  red  corpus- 
cles and  engorgement  or  collapse  of  the  air  cells  with  thinning  of  their 
walls.  About  the  infarct  is  a  zone  of  active  hyperemia.  Embolic  in- 
farctus  may  terminate  in  resolution  or  cicatrization,  but  if  infected  in 
abscess  or  gangrene.  Barely  caseation  and  calcification  with  encapsula- 
tion occur. 

Etiology. —  Thrombosis  may  be  due  to  local  vascular  degeneration  or 
inflammation  extending  from  the  adjacent  lung  tissue,  especially  in  con- 
nection with  feeble  heart  power. 

Embolism  may  be  due  to  loosened  fragments  from  the  cardiac  valves 
or  from  systemic  venous  thrombi  or  to  fat-granules  drawn  into  the  open 
veins  at  the  site  of  a  fracture  or  crushing  injury  to  the  long  bones. 

Symptomatology. — The  principal  symptoms  are  sudden,  severe,  and 
sometimes  paroxysmal  dyspnoea,  turbulent  heart  action,  and  pulsation 
of  the  jugulars,  from  yielding  of  the  tricuspid  valve.  Exaggerated  res- 
onance is  sometimes  detected,  owing  to  cutting  off  of  the  blood  supply 
from  some  of  the  pulmonary  lobules,  and  consequent  distention  of  the 
air  cells.  In  the  same  locality,  the  respiratory  murmur  will  be  feeble 
or  suppressed. 

Diagnosis. — Neither  the  symptoms  nor  the  signs  of  these  conditions 
are  sufficiently  well  understood  to  enable  us  to  make  a  positive  diagno- 
sis in  every  instance.  Most  reliance  must  be  placed  on  the  symptoms 
and  history. 

Peognosis. — The  prognosis  is  unfavorable  in  proportion  to  the 
amount  of  lung  damaged  by  the  emboli  or  thrombus,  and  is  always 
very  grave  if  the  emboli  be  infected.  Small  infarcts  may  undergo  reso- 
lution. Death  occurs  from  collapse,  apncea,  or  from  secondary  pneu- 
monia, sepsis,  or  phthisis. 

Teeatmekt. — The  treatment  must  be  expectant. 

PULMONARY  COLLAPSE. 

Synonyms. — Apneumatosis  and  atelectasis.  The  latter  term,  though 
referring  to  the  same  anatomical  condition  as  the  former,  is  more  prop- 
erly applied  to  air  cells  which  remain  in  the  fcetal  condition  after  birth, 
not  becoming  distended  with  air. 

Pulmonary  collapse  is  a  condition  of  the  lungs  in  which  air  cells 
which  have  formerly  been  inflated  have  collapsed,  and  returned  to  a 
quasi-foetal  state. 

Anatomical  and  Pathological  Chaeacteeistics. — Both  the  ac- 
quired and  the  congenital  forms  may  involve  the  whole  or  part  of  one 
lung  or  a  part  of  each;  the  collapsed  air  cells  being  en  masse  or  in  iso- 
lated lobules  or  groups  of  lobules  scattered  through  the  organ.     In 


140  PULMONARY  DISEASES. 

order  of  frequency,  the  parts  affected  are:  the  lower  margin  of  the  lower 
lobes  of  both  lungs,  the  tongue-like  prolongation  of  the  left  upper  lobe, 
and  the  posterior  portions  of  the  lower  and  upper  lobes  of  both  lungs 
near  the  spine.  The  collapsed  parts  correspond  externally  to  small  irreg- 
ular areas  depressed  below  the  general  surface  of  a  reddish-blue,  violet  or 
grayish-blue  color.  The  cross-section  is  dark  red,  smooth,  tough,  airless, 
and  the  part  readily  sinks  in  water.  Recently  collapsed  air  sacs  may  be  in- 
flated, but  if  this  condition  long  persists,  distention  becomes  impossible 
and  the  parts  subsequently  undergo  fatty  or  fibroid  change  or  become 
the  seat  of  tuberculosis.  The  surrounding  lung  tissue  is  not  infre- 
quently emphysematous  or  cedematous ;  the  bronchi  which  are  still  per- 
vious are  frequently  dilated.  Permanent  and  extensive  collapse  from 
prolonged  compression  results  in  a  dense,  solid,  fleshy  condition  of  the 
lung,  termed  carnification. 

Etiology. — The  affection  is  most  frequent  in  early  childhood.  It  is 
always  preceded  by  inflammation  of  the  bronchial  mucous  membrane, 
the  secretions  from  which  collect  in  some  of  the  smaller  bronchial  tubes, 
where,  acting  as  ball  valves,  they  obstruct  the  entrance  of  air  during 
inspiration,  but  permit  its  escape  in  expiration.  Ultimately  the  air 
cells  to  which  the  obstructed  bronchus  is  distributed  become  in  this 
manner  completely  emptied  of  air  and  collapsed. 

Congenital  atelectasis  occurs  in  weak  and  sickly  infants  or  may  be 
due  to  premature  delivery,  and  it  may  result  from  accidents  in  birth, 
such  as  the  inspiration  of  amniotic  and  other  fluids. 

In  children,  more  or  less  permanent  collapse  is  apt  to  follow  an  at- 
tack of  bronchitis,  whooping-cough,  measles,  typhoid  fever,  severe  diar- 
rhoea, or  any  other  exhausting  disease.  Disease  of  the  brain  or  spinal 
cord  interfering  with  the  pneumogastric  nerve  may  cause  it.  Collapse 
of  the  lung  may  be  due  to  the  pressure  of  mediastinal  or  intra-pulmo- 
nary  tumors,  or  to  effusion  into  the  pleural  sac. 

Symptomatology. — The  essential  symptoms  are:  great  prostration; 
pallor  or  duskiness  of  the  skin,  which  hangs  in  loose  folds  on  the  ema- 
ciated limbs;  rapid,  feeble  pulse  and  coldness  of  the  extremities;  a  feeble, 
insufficient  cough;  great  dyspnoea,  without  the  lividity  which  usually 
attends  this  symptom,  and  rapid  respiration,  rising  in  young  children 
from  sixty  to  eighty  per  minute,  with  an  altered  rhythm  in  the  respira- 
tory acts.  In  this  alteration  of  rhythm  the  pause  follows  inspiration 
and  precedes  expiration,  instead  of  occurring  between  expiration  and 
inspiration,  as  in  health. 

The  chief  signs  are :  retraction  of  the  intercostal  spaces  and  lower 
ribs  during  inspiration,  dulness  over  the  collapsed  lung  when  the  apneu- 
matosis  is  considerable,  and  feeble  or  absent  vesicular  murmur,  usually 
with  harsh  or  bronchial  respiration  over  the  affected  parts. 

Inspection  reveals  the  rapidity  of  respiration  and  its  changed  rhythm 
and  retraction  of  the  intercostal  spaces  and  lower  ribs  during  inspira- 


PULMONARY  COLLAPSE.  141 

tion.     The  latter  is  a  very  important  sign,  but  it  also  occurs  in  other 
diseases. 

In  children  the  signs  of  percussion  are  not  so  reliable  as  in  adults, 
but  when  the  disease  is  well  marked,  more  or  less  dulness  will  be  found 
over  the  affected  portions,  usually  first  at  the  base  of  the  lungs,  then  at 
their  anterior  borders,  and  finally  along  the  spinal  column.  If  a  whole 
lobe  is  involved,  dulness  like  that  of  pneumonia  will  be  present.  Not 
infrequently  the  collapsed  cells  are  so  scattered  through  the  lungs,  and 
the  adjacent  cells  are  so  distended,  that  the  affection  may  be  quite  ex- 
tensive without  giving  any  signs  on  percussion. 

By  auscultation,  harsh  or  bronchial  respiration  may  be  heard  over 
the  collapsed  cells  instead  of  the  vesicular  murmur. 

Usually  portions  of  the  lung  immediately  surrounding  the  affected 
lobules  remain  pervious  to  air,  so  that  the  vesicular  murmur  is  not  en- 
tirely lost;  the  sounds  from  the  air  vesicles  are  then  mingled  with  those 
from  the  bronchi,  causing  broncho-vesicular  respiration.  Ordinarily, 
numerous  bronchial  rales  are  present,  which  may  completely  mask  the 
vesicular  murmur. 

Diagnosis. — Pulmonary  collapse  is  most  likely  to  be  mistaken  for 
pneumonia  or  pleuritic  effusions. 

The  diagnosis  in  many  cases  must  depend  mainly  on  the  symptoms, 
as  the  signs  are  by  no  means  distinctive.  Whenever  dulness  occurs,  its 
rapid  appearance,  within  twenty-four  or  thirty-six  hours  succeeding  the 
signs  of  bronchitis,  is  an  element  of  great  value  in  diagnosis. 

In  pulmonary  collapse  there  are  few  if  any  crepitant  rales,  which  are 
considered  pathognomonic  of  pneumonia.  In  the  latter  disease  there  is 
not  the  retraction  of  the  chest  noticed  in  collapse,  and  dulness  is  usually 
greater  and  the  bronchial  breathing  more  marked  than  in  the  disease 
under  consideration.  The  fever  symptoms  are  more  marked  in  pneu- 
monia. 

The  features  that  distinguish  pleurisy  from  pulmonary  collapse  are 
the  flatness  instead  of  dulness  on  percussion,  change  in  the  level  of  flat- 
ness and  absence  of  vocal  fremitus,  and  feebleness  or  absence  of  respira- 
tory sounds  over  pleural  effusions. 

Pkogxosis. — Mild  atelectasis  in  the  new-born,  not  dependent  upon 
congenital  defect,  may  be  corrected  if  restorative  measures  be  early  ap- 
plied and  long  continued.  If  of  long  duration,  or  when  in  adults  due  to 
extreme  compression,  the  affection  is  liable  to  be  permanent  and  to  cause 
more  or  less  emphysema  and  finally  to  give  rise  to  lobular  pneumonia 
or  phthisis. 

Atelectasis  following  bronchitis  and  whooping-cough  is  especially 
fatal.  According  to  Loomis  (Practice  of  Medicine,  p.  158),  twenty- 
five  per  cent  of  the  total  mortality  in  young  infants  results  from  atelec- 
tasis following  bronchitis. 

Teeatment. — Having  fairly  established  the  respiratory  functions  at 


142  PULMONARY  DISEASES. 

birth  by  the  ordinary  methods  of  the  obstetrician,  it  must  not  be  for- 
gotten in  the  subsequent  treatment  of  this  condition  that  debility  is  the 
chief  factor  in  its  production.  Treatment  must  therefore  be  supporting 
from  the  first.  We  must  also  attempt  to  remove  the  secretions  from 
the  bronchi,  so  as  to  prevent  implication  of  other  air  cells.  With  this 
in  view,  a  non -depressing  emetic  may  be  given  when  the  debility  is  not 
very  great,  but  it  is  generally  unsafe  to  re])eat  it.  In  mild  cases  expec- 
torant doses  of  ipecac  are  useful.  In  severe  cases  ammonium  carbonate 
or  ammonium  iodide  with  alcoholic  stimulants  are  indicated.  Counter- 
irritation  of  the  surface  by  means  of  vigorous  friction  or  sinapisms  is 
useful  in  most  cases.  The  diet  should  be  nourishing,  but  not  too  con- 
centrated. Concentrated  nourishment  is  apt  to  derange  the  digestive 
organs,  and  do  more  harm  than  good. 

PULMONARY   CEDEMA. 

Pulmonary  oedema  consists  of  an  interstitial  extravasation  of  serum 
with  effusion  into  the  vesicular  portion  of  the  lungs,  which  renders  the 
cells  and  bronchioles  correspondingly  impervious  to  air. 

Anatomical  and  Pathological  Characteristics. — Pulmonary 
oedema  may  occur  either  ante  mortem  or  post  mortem;  a  given  case  can 
only  be  settled  by  reference  to  the  history,  and  the  symptoms  and  signs 
present  before  death.  It  affects  most  frequently  the  dependent  parts  of 
the  lungs,  but  it  may  involve  the  whole  or  any  part  of  one  or  both.  In 
well-marked  oedema,  the  pleura  is  moist,  and  its  cavity  may  contain 
serum.  The  lung  does  not  collapse  on  opening  the  chest,  and  is  abnor- 
mally light  colored,  unless  the  oedema  is  due  to  hyperemia.  It  is  heavier 
than  normal,  and  pits  on  pressure.  The  serum  oozing  from  the  cut  sur- 
face is  frothy  in  proportion  to  its  admixture  with  air;  very  slightly  so  if 
the  alveoli  and  bronchioles  are  almost  completely  filled  with  serum.  It 
has  a  reddish  tinge  if  the  affection  is  due  to  hyperemia,  is  always  albu- 
minous, and  usually  contains  alveolar  epithelium,  but  unless  due  to  hy- 
peremia it  holds  but  few  intra- vascular  cellular  elements. 

Etiology. — Pulmonary  oedema  is  probably  due  in  every  case  to  one 
of  three  causes,  viz. :  abnormal  permeability  of  the  vascular  walls  from 
changes  incident  to  certain  diseases  :  increase  of  intra-vascular  pressure 
from  active  or  passive  hyperemia,  or  change  in  the  character  of  the 
blood;  two  or  all  of  these  factors  may  co-operate  in  its  causation. 

It  is  not  infrequently  associated  with  general  dropsy  dependent  upon 
cardiac  or  renal  disease.  It  may  occur  from  heart  failure  in  the  course 
of  acute  general  disease  such  as  typhoid  fever,  or  in  purpura,  scorbutus, 
anemia,  and  other  chronic  affections. 

It  may  occur  in  one  lung  or  a  part  of  a  lung  from  the  presence  in 
the  other  parts  of  collapse  or  consolidation ;  and  hence  it  often  compli- 
cates pneumonia,  phthisis,  or  pressure  from  tumors  or  pleuritic  effusion. 


PULMONARY  (EDEMA.  143 

Symptomatology. — The  chief  symptoms  are  dyspnoea,  increased 
rapidity  of  respiration,  and  cough  with  frothy  expectoration. 

The  principal  signs  are  very  moist  subcrepitant  rales,  with  more  or 
less  dulness  over  the  base  of  the  lungs. 

Inspection,  palpation,  and  mensuration  yield  no  characteristic  signs. 
Respiration  is  increased  in  frequency. 

By  percussion,  dulness  is  obtained  on  both  sides  over  the  most  de- 
pendent portions  of  the  lungs. 

On  auscultation,  there  is  a  feeble  respiratory  murmur,  which  may  be 
slightly  broncho -vesicular,  with  abundant  moist  and  crackling  subcrepi- 
tant rales.  These  sometimes  resemble  the  crepitant  rales  of  pneumonia, 
but  they  are  more  moist,  not  so  numerous,  and  are  usually  heard  in  ex- 
piration as  well  as  in  inspiration.  The  vocal  resonance  may  be  in- 
creased. 

Diagnosis. — Pulmonary  oedema  is  liable  to  be  mistaken  for  the 
first  and  third  stages  of  pneumonia,  for  hydrothorax,  and  capillary  bron- 
chitis.    The  distinctive  signs  between  these  diseases  are  as  follows : 

Pulmonary  cedema.  Pneumonia,  first  and  third  stages. 

Percussion. 
Slight  dulness  upon  both  sides.  Dulness  more  or  less  marked,  usu- 

ally confined  to  one  side. 
Auscultation. 

Mucous  and  subcrepitant  rales  on  Crepitant  and  subcrepitant  rales  on 

both  sides.  one  side. 

Pulmonary  cedema.  Hydrothorax. 

Palpation. 
Vocal  fremitus  may  or  may  not  be  Vocal  fremitus  absent. 

increased. 

Percussion. 

Moderate  dulness,  the  upper  level  of  Flatness,   the  upper  line  of  which 

which  does  not  vary  with  changes  in        varies  with  the  changes  in  the  patient's 
the  patient's  position.  position. 

Auscultation. 

Subcrepitant  rales.  Absence  of  the  respiratory  murmur 

and  rales. 

Pulmonary  oedema  is  distinguished  from  capillary  bronchitis  by  the 
history,  the  presence  of  considerable  dulness  on  percussion,  and  by  ab- 
sence of  the  signs  and  symptoms  of  general  bronchitis. 

Prognosis. — The  prognosis  is  always  gfrave  in  pulmonary  cedema  ac- 
companying general  dropsy.  (Edema  is  frequently  the  cause  of  death 
in  pneumonia.  Extreme  dyspnoea  with  bubbling  rales  and  rapidly  de- 
veloping cyanosis  coming  on  in  such  affections  indicates  a  fatal  termina- 
tion. 

Treatment. — The  treatment  of  this  condition  will  depend  upon  the 


144  PULMONARY  DISEASES. 

disease  with  which  it  is  associated.  If  it  results  from  Bright's  disease, 
sudorifics  and  cathartics  will  be  necessary  to  stimulate  the  other  emunc- 
tories.  Diuretics  will  also  be  useful  in  some  cases,  but  the  crippled 
kidnevs  cannot  respond  readily  to  our  efforts  to  increase  their  functional 
activity. 

If  the  condition  is  dependent  upon  disease  of  the  heart,  digitalis  will 
be  specially  useful.  If  it  results  from  debility,  induced  by  low  forms  of 
disease,  general  stimulation  is  very  essential,  and  diuretics  and  sudorifics 
are  indicated. 

If  it  results  from  pulmonary  congestion,  active  counter- irritation  by 
sinapisms  or  dry  cups  should  be  made,  and  diuretics,  sudorifics,  and 
cathartics  should  be  simultaneously  employed,  care  being  taken  not  to 
exhaust  the  patient. 

Digitalis,  scoparius,  potassium  acetate,  and  ammonium  acetate  are 
the  best  diuretics.  Jaborandi  and  the  hot-air  or  vapor  bath  are  the 
most  suitable  means  to  cause  sweating. 

Saline  cathartics,  and  elaterium  or  euonymus  may  be  employed  when 
it  is  desired  to  act  on  the  bowels. 

"When  patients  are  greatly  depressed  from  protracted  disease,  care 
should  be  taken  to  prevent  pulmonary  cedema,  by  frequently  changing 
their  position  from  the  back  to  the  sides,  and  vice  versa. 

PULMONARY   GANGRENE. 

Pulmonary  gangrene  is  a  putrefactive  necrosis  of  lung  tissue,  result- 
ing from  pneumonia,  septicaemia,  or  local  injuries. 

Anatomical  and  Pathological  Characteristics.  —  Gangrene 
usually  occurs  at  the  lower  part  of  the  lung,  and,  according  to  Flint,  on 
the  posterior  aspect  of  the  upper  portion  of  the  lower  lobe.  It  is 
usually  confined  to  a  few  lobules,  but  sometimes  is  diffused  throughout 
a  large  part  or  even  the  whole  of  a  lobe. 

A  part  of  the  lung  which  is  entirely  deprived  of  its  blood  supply 
undergoes  coagulation  necrosis.  Being  exposed  to  the  action  of  innumer- 
able bacteria,  the  devitalized  tissues  speedily  exhibit  the  characteristics 
of  moist  gangrene.  They  become  a  dark  brown,  dirty  mass,  which  lique- 
fies, and  appears  in  the  expectoration  as  a  greenish-black,  extremely  fetid 
fluid,  containing  organic  germs,  shreds  of  tissue,  pus  corpuscles,  oil 
globules,  pigment  granules,  and  various  products  of  chemical  decompo- 
sition. Circumscribed  gangrene  is  surrounded  by  a  line  of  hypera?mic 
demarcation  not  present  in  the  diffuse  form.  The  discharge  of  the 
ichorous  slough  leaves  an  irregular  cavity,  intersected  by  vessels  more 
or  less  occluded  by  thrombi.  The  walls,  at  first  ragged,  may  granulate, 
and  by  contraction  finally  obliterate  the  space,  or  a  chronic  abscess 
may  result.  The  process,  at  first  limited,  may  become  diffuse;  in  this 
form  perforation   of  the  pleura  not   infrequently   occurs.     From  the 


PULMONARY  GANGRENE.  145 

local  thrombi  in  the  pulmonary  and  bronchial  vessels,  metastatic  septic 
emboli  may  establish  secondary  abscesses,  in  distant  organs. 

Etiology. — Gangrene  may  develop  in  the  course  of  bronchitis,  pneu- 
monia, phthisis,  cancer,  or  other  pulmonary  diseases,  and  may  follow 
severe  penetrating  wounds  or  the  entrance  of  foreign  bodies  into  the 
larger  bronchi.  It  may  complicate  pyaemia,  septicaemia,  or  certain  of 
the  prolonged  debilitating  fevers. 

Symptomatology. — The  principal  symptoms  are  great  prostration, 
pallor,  emaciation,  rapid  pulse,  rapid  and  oppressed  respiration,  haemop- 
tysis, and  cough,  with  abundant  greenish,  brownish,  or  blackish  purulent 
sputum  of  a  sickening  gangrenous  odor,  and  containing  fragments  of  the 
decomposing  lung.  The  odor  is  not  perceived  in  the  breath  constantly, 
but  mainly  after  coughing. 

The  most  prominent  signs  are:  dulness  on  percussion,  with  large 
and  small  mucous  rales ;  bronchial  breathing  or  absence  of  the  respira- 
tory murmur;  and,  when  the  slough  has  been  thrown  off,  gurgles  and 
respiratory  sounds  indicative  of  a  cavity.  The  disease  at  first  presents 
the  signs  of  consolidation,  which  are  soon  followed  by  breaking  down  of 
the  lung  tissue,  and  the  production  of  vomicae. 

Diagnosis. — Most  of  the  symptoms  and  physical  signs  are  not  distinc- 
tive, as  the  same  may  be  found  in  phthisis,  bronchitis,  or  dilatation  of 
the  bronchial  tubes,  The  diagnosis  must  therefore  rest  upon  the  char- 
acter and  the  odor  of  the  expectoration,  which  may  be  considered 
pathognomonic. 

Small,  circumscribed  patches  of  gangrene,  which  occasionally  occur 
in  bronchitis  or  around  tubercular  deposits,  cause  fetid  breath  and  fetid 
expectoration.  The  odor  in  these  cases  is  only  temporary,  whereas  in 
diffuse  gangrene  the  fetor  is  persistent,  though  most  marked  after  each 
act  of  cough  and  expectoration. 

In  bronchial  dilatation  or  bronchiectasis  the  sputum  is  abundant  and 
fetid,  but  not  brownish  in  color,  and  the  breath  has  not  that  peculiar, 
sickening  odor  of  gangrene,  which,  once  impressed  on  the  olfactory 
sense,  is  not  easily  forgotten. 

Prognosis.  —This  depends  largely  upon  the  cause  of  the  gangrene, 
and  upon  the  extent  of  lung  involved.  In  the  diffuse  form,  death  is 
inevitable,  usually  within  a  few  days.  In  the  circumscribed  form,  re- 
covery may  occur,  but  in  either  case  there  is  great  danger  from  pyaemia 
and  sepsis.     Death  may  result  from  acute  hemorrhage  or  exhaustion. 

Treatment. — Quinine,  tincture  of  iron,  alcoholics,  and  nourishing 
diet  are  the  chief  remedies  in  this  affection.  Inhalations  of  thymol, 
carbolic  acid,  creasote,  eucalyptol,  or  turpentine  may  be  useful  in  modi- 
fying the  offensive  odor  and  in  limiting  the  amount  of  discharge. 
Anodynes  should  be  used  to  soothe  pain.  Cases  of  cure  are  reported 
from  external  incision  and  drainage,  conjoined  with  internal  medica- 
tion. 


146  PULMONARY  DIkiEASEb. 


PULMONARY    CANCER. 


Pulmonary  cancer  is  fortunately  a  rare  disease.  It  is  usually  of  the 
medullary  variety,  though  scirrhus,  epithelioma,  and  other  varieties  also 
occur. 

Anatomical  and  Pathological  Characteristics. — Cancer  may 
occur  in  miliary  bodies  scattered  throughout  the  entire  lung,  or  in 
nodules  ranging  from  two  to  ten  or  twelve  pounds  in  weight;  or  the 
lung  tissue  may  be  almost  supplanted  by  the  malignant  deposit. 

Whether  primary  or  secondary,  single  or  multiple,  the  ultimate  result 
of  pulmonary  cancer  is  destruction  of  the  lung  immediately  involved, 
by  pressure,  atrophy,  or  by  infiltration  with  the  cancer  cells  and  the  pro- 
ducts of  their  degeneration.  Extension  occurs  chiefly  along  the  lym- 
phatic spaces.  While  growth  proceeds  at  the  periphery  of  the  cancer,  dis- 
organization takes  place  at  its  centre,  where  a  cavity  is  usually  formed 
after  a  time.  About  the  cancerous  nodules  not  infrequently  the  lung 
becomes  congested,  inflamed,  oadematous,  collapsed,  or  emphysematous. 
There  is  always  enlargement  of  the  bronchial  glands,  and  usually  pleu- 
ritis,  with  extensive  thickening  and  adhesions,  and  effusion  of  bloody 
serum  into  the  pleural  sac. 

Etiology. — Pulmonary  cancer  rarely  develops  before  the  twentieth 
year,  and  more  frequently  affects  men  than  women.  Heredity  can  usu- 
ally be  traced.  It  may  spring  primarily  from  the  epithelial  or  connective 
tissue  of  the  lung,  according  to  its  type. 

More  frequently  it  is  secondary  to  cancer  in  other  parts,  which  pen- 
etrates the  lungs  by  direct  growth  or  by  embolic  cells  through  the  cir- 
culation. 

Symptomatology. — The  most  marked  symptoms  are  pain  and  ema- 
ciation, with  some  dyspnoea  and  cough,  and  often  bloody  expectoration 
which  resembles  currant  jelly. 

The  signs  vary  with  the  conditions.  If  only  the  bronchial  mucous 
membrane  is  affected  by  the  cancerous  deposit,  we  obtain  simply  the 
signs  of  bronchitis.  If  the  air  vesicles  are  filled,  we  obtain  the  signs  of 
pulmonary  consolidation,  as  in  pneumonia.  When  softening  and  ulcera- 
tion have  occurred,  cavernous  signs  are  sometimes  obtained.  If  part  of 
the  air  vesicles  are  filled,  and  others  remain  open,  we  obtain  broncho- 
vesicular  respiration  and  other  signs  similar  to  those  of  phthisis. 

The  occurrence  of  the  nodular  variety  of  cancer  in  the  lung  gives 
rise  to  signs  which  are  often  distinctive.  We  generally  notice  the  fol- 
lowing: 

Inspection  reveals  more  or  less  loss  of  motion  and  retraction  or 
bulging  of  the  thoracic  walls  on  the  affected  side;  the  former  when  the 
lung  has  collapsed,  the  latter  when  the  growth  is  peculiarly  large  or 
when  considerable  pleuritic  effusion  is  present. 


PULMONARY  CANCER.  147 

On  palpation,  vocal  fremitus  will  be  feeble  or  suppressed,  according 
to  the  proximity  of  the  tumor  to  the  chest  walls. 

Percussion,  most  frequently  near  the  middle  or  the  upper  part  of 
the  chest,  will  show  dulness  or  flatness  over  the  tumor,  according  to  its 
nearness  to  the  chest  walls.  In  many  instances,  over  one  or  more  places 
resonance  remains  normal,  surrounded  by  areas  of  flatness,  owing  to  the 
presence  of  a  small  portion  of  healthy  lung  surrounded  by  a  cancerous 
mass. 

On  auscultation,  the  respiratory  sounds  may  be  feeble  or  entirely  sup- 
pressed over  the  tumor.  Occasionally  the  cancer  rests  upon  a  large 
bronchial  tube,  in  such  a  position  that  the  sounds  from  the  latter  are 
transmitted  to  the  surface,  giving  rise  to  bronchial  breathing  and  bron- 
chophony. 

If  the  pleura  is  involved,  there  will  be  an  exudation  of  serum  into 
its  cavity,  yielding  the  signs  of  chronic  or  of  subacute  pleurisy.  Upon 
exploratory  aspiration,  the  fluid  is  often  found  more  or  less  sanguinolent. 

Diagnosis. — When  the  disease  is  primary,  it  is  very  difficult  to  de- 
tect. When  secondary  to  cancer  in  other  portions  of  the  body,  the 
occurrence  and  persistence  of  bronchial  or  other  pulmonary  signs  should 
lead  us  to  suspect  its  true  nature. 

Pulmonary  cancer  is  most  likely  to  be  mistaken  for  chronic  or  sub- 
acute pleurisy  with  effusion.  It  bears  some  resemblance  to  phthisis,  and 
also  to  aortic  aneurism. 

If  the  cancer  is  attended  with  effusions  into  the  pleural  sac,  an  accu- 
rate diagnosis  cannot  be  made  by  the  ordinary  methods,  but  the  charac- 
ter of  the  fluid  obtained  by  aspiration  will  usually  enable  us  to  make  a 
correct  diagnosis. 

The  differential  points  between  the  nodular  variety  of  pulmonary 
cancer  and  clironic  pleurisy  will  be  seen  in  the  following  table : 

Pulmonary  cancer.  Chronic  pleurisy. 

Symptoms. 
Nearly  constant  pain,  and  often  cur-  Little,  if  any,  pain  ;  the  expectora- 

rant-jelly  expectoration.  tion,  if  any,  only  purulent. 

Percussion. 
Dulness  does  not  begin  at  the  base  Flatness  beginning  at  the  base  of 

of  the  lung  ;  usually  one  or  more  iso-        the  lung,  uniform  to  its  upper  limit, 
lated   spots  of  resonance   within  the 
area  of  dulness  or  flatness. 

Auscultation. 
Usually  some  respiratory  signs,  due  Absence  of  the  resph'atory  murmur, 

to  isolated  portions  of  normal  lung,  or  and  usually  of  the  bronchial  sounds  ; 
to  only  partial  consolidation  of  the  the  latter  when  heard  are  diffused  and 
pulmonary  parenchyma.  distant. 

Aspiration. 
Sometimes  a  sanguinolent  fluid.  The  Serous  or  purulent  fluid  is  obtained, 

fluid,   when  serous,  coagulates  much 
more  slowly  than  in  pleurisy. 


148  PULMONARY  DISEASES. 

Cancer  of  the  lung  is  not  likely  to  be  mistaken  for  phthisis,  though 
such  an  error  might  be  made.  The  cancerous  growth  does  not  often 
begin  in  the  apex  of  the  lung,  and  it  may  become  very  extensive  without 
causing  bronchial  rales.     The  reverse  is  true  in  phthisis. 

The  history  of  aortic  aneurism  is  different,  as  intra-thoracic  cancer  is 
nearly  always  secondary  to  external  manifestations.  The  symptoms  due 
to  pressure,  viz.,  pain,  dyspnoea,  dysphagia,  and  venous  congestion  and 
pulsation,  are  less  persistent  in  aneurism  than  in  cancer. 

Aneurisms  usually  have  a  distinct  expansile  pulsation,  and  when 
they  cause  a  murmur,  it  is  likely  to  be  double,  that  is,  systolic  and  dia- 
stolic. Cancers  have  no  pulsation  excepting  that  communicated  from 
the  aorta,  and  this  is  feeble  and  simply  lifting.  If  a  cancerous  growth, 
by  pressure  on  the  artery,  causes  a  murmur,  it  is  always  systolic,  no 
second  sound  being  produced. 

Prognosis. — The  prognosis  is  always  hopeless.  Death  usually  re- 
sults within  a  year. 

Treatment. — 'Anodynes  to  relieve  pain  are  the  only  remedies  that 
can  be  recommended.  None  of  the  remedies  which  have,  from  time  to 
time,  been  recommended  for  the  cure  of  cancer  have  borne  the  test  of 
experience. 

PULMONARY   TUMORS. 

Tumors  or  morbid  growths  in  the  lungs  may  result  from  hydatids, 
syphilis,  enlargement  of  glands,  abscesses,  and  malignant  disease. 

HYDATID   CYSTS   OF   THE   LUNGS. 

Hydatid  cysts  in  the  lungs  constitute  a  rare  affection,  which  presents 
symptoms  and  signs  similar  to  those  of  phthisis.  The  cyst  most  fre- 
quently occupies  the  lower  lobe  of  the  right  lung,  and  is  generally  sec- 
ondary to  hydatids  of  the  liver. 

Anatomical  axd  Pathological  Characteristics. — The  wall  of 
a  hydatid  c}rst  is  composed  of  an  outer  and  an  inner  layer,  and  the  cyst 
contains  a  clear  fluid  non-coagulable  by  heat  or  acid.  From  the  inner 
membrane  develop  young  echinoeocci  with  characteristic  hooklets ;  these 
cysts  may  in  turn  develop  within  themselves  others  of  similar  form. 

The  growth  after  attaining  a  variable  size  may  by  fatty  degeneration 
of  its  contents  undergo  evolution  and  largely  disappear,  or  it  may  re- 
main permanently  as  the  seat  of  calcification.  Suppuration  may  occur 
within  the  cyst,  and  its  subsequent  course  may  be  that  of  an  abscess. 
Again,  by  gradual  increase  in  size,  it  may  produce  great  disturbance  by 
its  pressure,  by  exciting  inflammation,  or  by  rupture  into  the  surround- 
ing lung  or  pleural  cavity. 

Etiology. — The  ova  of  the  taenia  echinococcus,  which  commonly  in- 
habits the  intestinal  tract  of  dogs  and  other  animals,  upon  entering  the 


HYTADID  CYSTS  OF  THE  LUNGS.  149 

human  stomach  are  freed  from  their  capsules  by  the  digestive  fluids. 
Thence  the  parasites  burrow  to  the  viscera,  chiefly  the  liver,  and  become 
hydatid  cysts.  The  disease  is  rare  in  this  country,  and  is  seldom  found 
excepting  among  people  who  mingle  freely  with  the  lower  animals. 

Symptomatology. — The  symptoms  are  like  those  of  phthisis,  viz., 
emaciation,  night-sweats,  cough,  dyspnoea,  and  expectoration  of  bloody 
and  purulent  sputa.  Finally,  hydatid  cysts,  or  portions  of  them,  and 
the  hooklets  of  the  echinococci  may  be  thrown  off  through  the  bronchi. 

Symptoms  of  pyrexia  are  due  to  the  secondary  inflammation,  not  to 
any  specific  action. 

The  principal  signs,  if  the  tumor  be  large,  are :  bulging  and  loss  of 
motion  of  the  side,  nodular  prominences  in  the  intercostal  spaces;  and, 
when  the  cysts  approach  the  surface  of  the  lung,  dulness  or  flatness  on 
percussion,  with  suppressed  respiration  or  tubular  breathing.  A  positive 
diagnosis  can  seldom  be  made  until  the  hooklets  of  the  echinococcus 
are  discovered  in  the  sputum.  This  does  not  occur  until  late  in  the 
disease,  when,  after  death  of  the  entozoon,  it  begins  to  be  ejected  from 
the  body. 

According  to  Bird,  the  diagnosis  may  be  made  with  a  fair  degree  of 
certainty  early  in  the  disease  if  the  cyst  is  of  any  considerable  size  and 
impinges  against  the  chest  wall.  In  such  cases  the  following  signs  have 
been  noticed: 

Inspection  reveals  decubitus  always  on  the  sound  side.  The  respira- 
tory movements  of  the  affected  side  are  deficient,  and  there  may  be 
slight  bulging  in  one  or  more  places  along  the  intercostal  spaces,  over 
the  cysts. 

Vocal  fremitus  may  be  absent,  and  fluctuation  can  sometimes  be  de- 
tected over  the  cyst  by  palpation. 

On  percussion,  flatness  is  found  over  a  limited  area  corresponding  to 
the  cyst.  In  order  to  be  of  value  in  diagnosis,  this  area  of  flatness  should 
not  be  less  than  three  or  four  inches  in  diameter.  It  should  have  a 
rounded  outline,  and  it  must  be  clearly  separated  by  a  line  of  demarca- 
tion from  the  surrounding  resonance.  It  does  not  change  "with  the  posi- 
tion of  the  patient. 

In  auscultation  there  is  absence  of  the  respiratory  murmur  over  the 
area  of  flatness,  and  normal  respiration  around  it,  immediately  beyond 
the  line  of  demarcation.  The  compressed  lung  close  about  the  cyst  may 
cause  a  more  or  less  tubular  sound. 

Diagnosis. — The  affection  is  liable  to  be  mistaken  for  phthisis  or 
circumscribed  pleurisy.  Attention  to  the  differential  characters  noted 
in  the  following  table  will  aid  in  making  the  diagnosis: 

Hydatid  cysts  of  the  lungs.  Phthisis. 

Inspection. 
Prominence  of  the  intercostal  spaces.  No  prominence   of   the    intercostal 

spaces. 


150  PULMONARY  DISEASES. 

Hydatid  cysts  of  the  lungs.  Phthisis. 

Palpation. 
Absence   of  fremitus,    and   perhaps  Exaggerated     vocal     fremitus :    no 

fluctuation  over  the  cyst.  fluctuation  over  the  consolidated  lung. 

Percussioti. 
Flatness  over  the  cyst  sharply  de-  Dulness    over     consolidated     iung, 

fined  by  a  line  of  demarcation  from  the        gradually  fading  off  into  normal  res- 
resonance  of  the  surrounding  healthy        onance. 
structure. 

Microscopic. 

No  tubercle  bacilli  in  simple  eases.  Tubercle  bacilli  commonly   present 

in  the  sputum. 

Auscultation. 

Absence  of  respiratory  murmur  over  Broncho-vesicular     respiration,     or 

cyst  (flat  area).  cavernous  signs  over  dull  area. 

The  distinctive  features  between  hydatid  cysts  of  the  lungs  and 
circumscribed  pleurisy  are  as  follows: 

Hydatid  cysts  of  the  lungs.  Circumscribed  pleurisy. 

History. 
Usually  located  in  the  infra-clavicu-  Usually  located  at   the  base  of  the 

lar  or  axillary  regions.  chest. 

Symptoms  and  Signs. 
Gradual  accession  of  the  local  and  Usually  ushered  in  with  acute  febrile 

constitutional  symptoms.  symptoms. 

Inspection. 
Nodular  prominence  of  intercostal  Uniform  prominence  of  inter-costal 

spaces.  spaces. 

Percussion  and  Auscultation. 
Signs  usually  in  the  upper  part  of  the  Signs  generally  in  the  lower  part  of 

chest.  the  chest. 

Treatment. — As  the  disease  can  seldom  be  distinguished  from 
phthisis,  the  treatment  must  generally  be  the  same  as  for  the  latter. 
In  those  cases  where  the  disease  can  be  positively  diagnosticated,  aspira- 
tion of  the  cyst  and  injection  with  iodine  (Form.  11)  is  the  most  rational 
treatment. 

DISTOMA   PULMONALE. 

The  people  in  some  parts  of  China,  C'orea,  and  Japan,  by  the  use  of 
surface  or  ditch  water  in  the  preparation  of  uncooked  food,  and  for 
drinking  purposes,  are  liable  to  a  peculiar  form  of  pulmonary  disease 
due  to  entrance  into  the  lung  of  the  distoma  pulmonale,  which  infests 
these  waters.  It  is  an  animal  parasite  somewhat  resembling  an  ordinary 
leech  in  miniature,  being  eight  or  ten  millimetres  long,  with  oval  and 
ventral  suckers  by  which  it  effects  locomotion. 


SYPHILITIC  DISEASE  OF  THE  LUNGS.  151 

By  burrowing  in  the  walls  of  the  bronchi  it  causes  sacular  bronchi- 
ectatic  cavities,  surrounded  by  irregular  zones  of  congestion  and  indura- 
tion and  containing  debris,  mucus,  and  the  parasites  with  their  ova. 

Symptomatology. — The  symptoms  and  signs  are  those  of  chronic 
bronchitis  of  increasing  severity  associated  with  frequent,  and  often 
severe  hemorrhages. 

The  presence  of  the  characteristic  organism  in  the  expectoration, 
the  history  of  the  case,  and  the  geographical  locality  of  its  occurrence 
establish  the  diagnosis. 

Some  patients  recover  with  or  without  treatment,  but  the  affection 
is  of  long  duration  and  no  specific  medication  avails.  Prophylaxis  is 
the  most  important  part  of  treatment  (Annual  of  Universal  Medical  Sci- 
ences, 1888). 

SYPHILITIC   DISEASE   OF   THE   LUNGS. 

It  is  a  well-recognized  fact  that  syphilis  causes  a  morbid  condition 
of  the  lungs,  the  signs  of  which  in  no  way  differ  from  those  of  ordinary 
phthisis.  Cases  are  occasionally  observed  in  which  a  specific  form  of 
bronchitis  or  gummata  occurs  as  a  result  of  the  venereal  taint. 

The  signs  of  syphilitic  bronchitis  are  the  same  as  those  of  the  non- 
specific affection.  A  distinction  between  the  two  can  only  be  made  by 
attention  to  the  history  and  the  attendant  symptoms. 

Diagnosis. — The  differential  diagnosis  between  syphilitic  disease  of 
the  pulmonary  parenchyma  and  phthisis  is  extremely  difficult,  and 
often  impossible.  But  when  uncomplicated,  pulmonary  syphilis  usually 
differs  from  phthisis,  as  shown  in  the  following  table: 

Syphilitic  disease  of  the  lungs.  Phthisis. 

History  and  Symjrtoms. 

The  history  of  syphilis  ;  thickening  No  history  of  syphilis  ;  no  thickening 

of  the  periosteum  and  perichondrium  of  the  periosteum  or  perichondrium 
over  the  inner  end  of  the  clavicles,  and  over  the  clavicles  or  cartilages  of  the 
one  or  more  of  the  cartilages  of  the  upper  ribs,  and  no  sub-sternal  tender- 
upper  ribs,  with  sub-sternal  tenderness  ness.  Hectic  fever  and  marked  ema- 
on  pressure  over  the  upper  part  of  the  ciation  always  present,  with  usually 
sternum.  Usually  neither  fever  nor  de-  haemoptysis, 
cided  emaciation,  and  no  haemoptysis. 

Physical  Signs. 

Dulness   over   the  nodules,  usually  Durness   usually   at   the  apex,  and 

confined  to  one  lung,  and  found  at  its  gradually  extending  over  the  sur- 
base  or  at  the  lower  part  of  the  upper  rounding  lung, 
lobe.  The  dulness  remaining  circum- 
scribed for  a  long  time.  Viscid  sub- 
crepitant  rales,  or  several  mucous 
clicks,  diffused  over  a  considerable  por- 
tion of  the  lung,  are  believed  to  be  one 
of  the  earliest  indications  of  the  syph- 
ilitic affection  ;  later  the  auscultatory 
signs  are  the  same  as  those  of  phthisis. 


152  PULMONARY  DISEASES. 

Prognosis. — The  prognosis  is  favorable  in  uncomplicated  cases  when 
discovered  early. 

Treatment. — Anti-syphilitic  constitutional  remedies  as  iodine,  potas- 
sium iodide,  and  the  compounds  of  mercury  are  indicated.  If  these  were 
oftener  tried  in  cases  of  so-called  phthisis,  probably  more  would  be 
cured.  We  should  also  employ  tonic  and  supporting  measures,  similar 
to  those  recommended  in  pulmonary  phthisis. 

ENLARGED  BRONCHIAL  GLANDS. 

As  an  independent  affection,  this  is  of  rare  occurrence.  It  deserves 
attention  here  from  its  close  resemblance  in  some  particulars  to  phthisis. 

Anatomical  and  Pathological  Characteristics. — The  chief 
bronchial  glands  lie  at  the  bifurcation  of  the  trachea  and  about  the  two 
main  bronchi,  where  they  are  numerous  and  in  relation  in  front  with 
the  aorta,  pulmonary  artery,  and  pericardium;  behind  with  the  aorta, 
oesophagus,  vena  azygos,  and  sympathetic  plexus.  Those  about  the 
bronchi  are  also  adjacent  to  the  large  venous  and  arterial  branches  and 
pneumogastric  and  recurrent  laryngeal  nerves. 

Enlargement  of  these  glands  occurs  from  engorgement  and  increase 
of  interstitial  connective  tissue  with  thickening  of  the  capsule.  When 
acute,  suppuration  may  occur. 

Etiology. — Some  enlargement  of  the  bronchial  glands  usually  ac- 
companies inflammation  of  the  lung  or  bronchitis;  it  is  marked  in 
phthisis,  syphilis,  and  malignant  disease  of  these  organs.  It  also  occurs 
to  some  extent  in  typhoid  fever,  measles,  whooping-cough,  and  other  in- 
fectious diseases. 

Symptomatology. — The  prominent  symptoms  are:  a  dry,  ringing, 
and  paroxysmal  cough  like  that  of  pertussis  but  without  the  whoop; 
with  dyspnoea,  and  more  or  less  pain  and  tenderness  on  pressure  near 
the  fourth  or  the  fifth  vertebra,  associated  with  emaciation,  hectic  flush, 
and  night-sweats. 

The  symptoms  vary  greatly  according  to  the  size  and  position  of  the 
enlargement.  Compression  of  the  bronchi  and  lungs  gives  rise  to  cough, 
expectoration,  and  dyspnoea. 

Pressure  upon  the  recurrent  laryngeal  nerve  produces  dyspnoea,  occa- 
sionally of  a  spasmodic  type,  and  may  also  cause  hoarseness  or  aphonia. 

Crowding  of  the  tumor  upon  the  oesophagus  produces  dysphagia; 
pain  and  tenderness  result  from  implication  of  the  sympathetic  plexus. 
Compression  of  the  pneumogastric  accounts  for  the  palpitation,  rapid 
pulse,  and  the  nausea  and  vomiting  that  sometimes  occur. 

On  inspection,  we  find  as  signs  frequently,  distention  of  the  cervical 
veins  and  sometimes  cyanosis,  rarely  deficiency  or  absence  of  respiratory 
movements  of  one  side  due  to  occlusion  of  the  main  bronchus. 

By  palpation  and  percussion,  tenderness  may  usually  be  detected  over 


PERTUSSIS,    OR   WHOOPING-COUGH.  13  5 

the  bronchial  glands  in  the  interscapular  region  near  the  fourth  and 
fifth  dorsal  vertebras.  Circumscribed  dulness  over  the  enlarged  glands 
is  sometimes  found.  Compression  of  a  bronchus  may  cause  collapse  of 
the  lung,  with  consequent  uniform  dulness. 

By  auscultation,  we  usually  hear  numerous  rales  and  feeble  or 
harsh  respiration,  or  in  other  words  the  signs  of  consumption.  Some- 
times arterial  murmurs  may  be  detected.  Again,  pressure  on  a  bronchus 
may  cause  localized  rales  and  feeble  respiration;  or  it  may  prevent  respi- 
ratory sounds  in  the  portion  of  lung  supplied  by  that  bronchus.  In 
these  cases  a  deep  breath  will  frequently  bring  out  the  respiratorv  sound, 
where  it  could  not  be  heard  in  ordinary  respiration. 

Diagnosis. — Enlargement  of  the  bronchial  glands  cannot  usually 
be  distinguished  from  phthisis,  but  in  some  instances  a  reasonably  cer- 
tain differentiation  can  be  made  by  remembering  that  the  disease  under 
consideration  usually  occurs  at  an  earlier  age  than  phthisis,  and  that 
the  pain,  tenderness,  and  dulness  which  it  induces  are  first  found  in  the 
region  of  the  bronchial  glands,  instead  of  over  the  apex  of  one  lung. 

Prognosis. — The  prognosis  must  be  based  upon  the  evidences  of  the 
structures  involved,  the  size  of  the  enlargement,  and  its  rate  of  growth. 
A  simple  inflammatory  enlargement  may  be  arrested,  but  if  terminating 
in  suppuration  it  is  frequently  fatal.  -Syphilitic  adenitis  rapidly  yields 
to  appropriate  remedies.  Malignant  disease  in  this  locality  is  always 
fatal. 

Tuberculosis  of  these  glands  is  likewise  unfavorable. 

Treatment. — Treatment  is  usually  of  little  avail  in  this  disease,  but 
the  remedies  which  are  most  beneficial  in  scrofulous  enlargement  of  the 
superficial  glands  should  be  tried.  Iodine,  potassium  iodide,  calcium 
chloride  and  cod-liver  oil  may  be  used,  with  quinine  to  relieve  fever,  or 
iron  when  fever  is  not  present. 

The  diet  should  be  plain  but  nutritious,  and  all  the  surroundings  of 
the  patient  should  be  made  as  healthful  as  possible. 

PERTUSSIS,    OR  WHOOPEXG-COTJGH. 

Pertussis  is  an  infectious,  contagious  disease,  often  epidemic,  and  char- 
acterized by  paroxysmal,  spasmodic  cough  terminating  in  a  prolonged 
inspiratory  crowing  or  whooping  sound.  It  is  most  common  in  children 
under  ten  years  of  age;  it  is  rare  before  the  third  month;  it  seldom  affects 
adults  but  is  occasionally  observed  even  in  advanced  life.  One  attack 
usually  gives  immunity  from  later  ones. 

Anatomical  and  Pathological  Characteristics. — The  only  mor- 
bid condition,  found  in  fatal  cases  of  pertussis,  which  is  due  to  the  dis- 
ease specifically,  is  a  more  or  less  marked  catarrhal  inflammation  of  the 
upper  air  passages,  larynx,  trachea,  and  large  bronchi.  Other  patholog- 
ical conditions  present  are  secondary  and  due  largely  to  the  severity  of 


15±  PULMONARY  DISEASES. 

the  cough.  Pulmonary  vesicular  emphysema  is  commonly  present,  and 
sometimes  bronchiectasis,  chiefly  in  the  upper  lobes.  Pneumonia  and 
atelectasis  are  not  infrequent  complications.  There  may  be  congestion 
of  the  meninges  and  apoplectic  extravasation  into  the  brain,  associated 
with  effusion  of  serum  into  the  cerebral  cavities.  Prolapsus  ani  and 
hernia  are  occasionally  observed  as  results  of  the  cough,  and  more 
rarely,  rupture  of  the  membrana  tympani. 

Etiology. — It  is  highly  contagious  and  is  said  to  affect  even  the 
lower  animals.  Infection  is  usually  conveyed  directly  from  one  person 
to  another,  though  a  third  person  maybe  the  medium  of  communication. 
Eecent  evidence  favors  the  germ  theory  of  its  production,  but  as  yet  no 
one  micro-organism  has  been  discovered  as  the  sole  cause. 

A  stage  of  incubation  of  from  two  to  fourteen  days  precedes  the  ap- 
pearance of  catarrhal  symptoms. 

Symptomatology. — The  disease  is  conveniently  divided  into  a  catar- 
rhal, a  paroxysmal,  and  a  declining  stage.  Sneezing,  coryza,  epiphora, 
and  some  cough  characterize  the  first  period,  which  commonly  lasts  from 
one  to  two  weeks,  and  in  no  way  differs  from  an  ordinary  cold. 

The  more  severe  the  affection,  the  shorter  the  first  stage.  In  the 
second  period,  the  cough  becomes  a  series  of  short  expiratory  efforts 
ending  in  a  prolonged  inspiration  with  a  stridulous  whooping  sound 
caused  by  spasmodic  contraction  of  the  glottis. 

Generally  several  of  these  series  occur  in  succession,  terminating  with 
the  expectoration  of  a  small  amount  of  viscid  secretion,  and  with  some 
of  a  frothy  nature,  and  often  vomiting  of  a  large  amount  of  thick, 
glairy  mucus.  These  paroxysms  last  from  half  a  minute  to  a  minute  or 
longer,  and  recur  during  the  height  of  the  attack,  every  two  or  three 
hours,  or  sometimes  three  or  four  times  au  hour.  The  longer  the  inter- 
vals, the  more  severe  the  paroxysms.     They  are  more  frequent  at  night. 

Conjunctival  hemorrhage,  cedema  of  the  eyelids,  and  epistaxis  are 
frequently  caused  by  the  venous  congestion  which  occurs  during  the 
cough.  In  some  cases  there  is  marked  cyanosis,  followed  by  great  ex- 
haustion. Three  or  four  weeks  is  the  average  duration  of  the  second 
stage.  In  mild  cases  the  characteristic  cough  may  be  entirely  absent. 
In  some  cases  it  may  persist  as  a  habit  for  many  months  even  after  con- 
valescence. The  symptoms  of  the  third  stage  are  those  of  a  declining 
catarrhal  inflammation  of  the  air  passages,  which  usually  lasts  about  two 
weeks. 

Diagnosis. — The  diagnosis  rests  upon  the  history,  the  peculiar  char- 
acter of  the  cough,  and  the  expectoration  or  vomiting  of  large  quantities 
of  viscid  mucus.  Affections  of  the  bronchial  mucous  membrane,  or  of 
the  pulmonary  parenchyma,  which  are  frequently  developed  during  the 
course  of  pertussis,  yield  the  same  signs  as  when  they  occur  independ- 
ently. 

Pkogxosis. — Whooping-cough  is  a  serious  disease  among  infants.  The 


PERTUSSIS,   OR   WHOOPING-COUGH.  155 

prognosis  improves  with  increasing  age,  and  larger  children  seldom  suc- 
cumb to  the  affection,  excepting  when  it  is  complicated  by  other  disease. 
The  indications  are  good  if  the  patient  is  fairly  well  between  the  par- 
oxysms, but  evidence  of  illness  is  significant  of  some  complication.  In- 
tercurrent attacks  of  measles  or  other  diseases  are  unfavorable.  Bron- 
chitis and  broncho-pneumonia,  especially  the  latter,  frequently  cause  a 
fatal  termination.  Cerebral  congestion,  apoplexy  and  convulsions,  or 
more  rarely,  hemorrhage  from  a  mucous  surface  may  be  the  cause  of 
death. 

The  patient  may  die  from  emaciation  and  exhaustion  due  to  fre- 
quent vomiting.  The  affection  is  frequently  preceded  or  followed  by 
measles. 

Tkeatment. — Many  "specifics"  have  been  recommended  for  this 
disease,  but  none  have  proved  effectual. 

Morphine  and  chloral  may  be  given  in  doses  suited  to  the  age  of  the 
patient,  especially  to  adults  (Form.  2).  For  children  I  like  better  potas- 
sium and  ammonium  bromide  or  hydrobromic  acid  with  syrup  of  lactu- 
carium,  with  or  without  syrup  of  hydriodic  acid. 

Sulphate  of  quinine  in  large  doses,  given  in  solution  so  as  to  make 
the  strongest  possible  impression  on-  the  sense  of  taste,  has  been  highly 
recommended,  and,  according  to  reports  in  the  current  medical  litera- 
ture, it  will  cure  the  majority  of  cases  in  a  few  days;  but  my  own  expe- 
rience with  it  has  been  unsatisfactory. 

My  experience  with  the  preparations  of  anemone  pratensis,  thymus 
vulgaris  and  Oenothera  biennis  has  been  very  limited,  but  never  satisfac- 
tory. Antipyrine  in  doses  of  gr.  ij.  every  three  to  five  hours  for  a  child 
twelve  years  of  age,  to  be  discontinued  as  soon  as  any  cyanosis  ap- 
pears, is  highly  recommended  by  many;  and  bromoform  in  doses  of 
iTt  ss.-i.  for  a  child  of  the  same  age,  has  been  extolled  by  others. 


CHAPTER  X. 

PULMONARY   DISEASES.— Continued. 

PULMONARY   PHTHISIS. 

Under  pulmonary  phthisis  may  be  grouped  several  affections,  differ- 
ing somewhat  in  their  anatomical  characteristics,  but  closely  resembling 
each  other  in  their  physical  signs.  From  this  latter  fact,  it  is  especially 
appropriate,  in  the  matter  of  diagnosis,  to  consider  them  together.  The 
term  phthisis  will  then  include  all  those  wasting  pulmonary  affections 
which  are  attended  with  exudation  or  infiltration  into  the  pulmonary 
parenchyma,  causing  consolidation,  and  are  attended  or  followed  by  more 
or  less  induration  and  contraction  and  subsequent  breaking  down  of  lung 
tissue,  whether  these  diseases  be  the  result  of  a  simple  inflammatory 
affection,  or  the  cause  or  the  result  of  tubercular  infiltration.  The  term 
pulmonary  phthisis  will  therefore  include  fibroid  phthisis  and  the  ordi- 
nary acute  and  chronic  forms  of  pulmonary  tuberculosis.  Any  special 
symptoms  or  signs  which  are  of  value  in  differentiating  between  these 
various  conditions  will  be  separately  considered. 

Fibroid  phthisis  is  also  known  as  cirrhosis,  induration,  or  fibroid  de- 
generation of  the  lung;  sometimes  as  chronic  catarrhal  pneumonia,  and 
occasionally  as  bronchiectasis. 

The  ordinary  forms  of  phthisis  have  various  names,  as,  chronic 
croupous  pneumonia,  caseous  pneumonia,  cheesy  or  tuberculous  infiltra- 
tion of  the  lung,  chronic  tuberculosis,  and  pneumonic  phthisis. 

PULMONARY    TUBERCULOSIS. 

Pulmonary  tuberculosis  may  be  more  or  less  acute  or  chronic ;  run- 
ning its  course  within  a  period  of  six  months  or  a  year,  or  being  pro- 
longed in  exceptional  cases  for  many  years.  The  term  acute  tubercular 
phthisis  is  properly  applied  to  miliary  tuberculosis  of  the  lung  as  a  part 
of  a  generally  disseminated  disease. 

Anatomical  and  Pathological  Characteristics. — Upon  post-mor- 
tem examination  usually  both  lungs  are  found  to  be  affected.  A  lung 
which  is  the  seat  of  ordinary  tuberculosis  may  appear  superficially  normal 
or  mottled,  with  grayish-yellow  areas  over  which  minute  tubercles  may  be 
seen  in  the  pleura.  This  membrane  may  also  be  covered  with  an  inflam- 
matory exudate.  The  organ  is  heavier,  more  solid,  and  less  crepitant 
than  normal.  Section  usually  reveals  at  the  apex  one  or  more  ragged 
cavities,    and    yellow,    chee?y    masses,    some  of    which    may    be   semi- 


PULMONARY  PHTHISIS. 


15? 


fluid.  About  these  are  miliary  foci  of  caseation,  a  line  in  diameter, 
sharply  defined  to  the  naked  eye,  rounded,  firm,  translucent,  and  gray 
or  yellowish  in  color.  Throughout  the  rest  of  the  affected  lobe  or  the 
entire  organ  may  be  scattered  miliary  tubercles,  and  larger  areas  the  size 
of  a  pea,  more  yellow  in  color.  There  is  accompanying  bronchitis,  and 
from  the  severed  tubes,  some  of  which  are  dilated,  pus  may  be  pressed. 
The  non-tubercular  parts  of  the  lung  may  be  the  seat  of  emphysema  or  con- 
gestion and  oedema,  and  the  bronchial  glands  are  infiltrated  and  enlarged. 
In  acute  tuberculosis,  tubercle  bacilli  commonly  find  lodgment 
on  the  mucous  membrane  of  the  bronchioles  or  alveoli,  having  entered 
the  bronchi  with  the  inspired  air,  or  occasionally  by  rupture  into  the 


Fig.  23.—  Tubercle. 


a,  Giant  cell;  b.  epithelioid  cells;  c,  round  lymphoid  cells;  d,  fibrous 
reticulum. 


passages  of  a  tubercular  gland.  They  may,  however,  reach  the  lung 
through  the  circulation  by  one  or  more  emboli  from  a  distant  tuber- 
cular involvement  of  a  vein  or  the  thoracic  duct.  Whether  they  pri- 
marily gain  footing  on  the  epithelium  of  the  air  passages  or  on  the 
endothelium  within  the  vessels,  under  favoring  conditions  they  effect 
the  formation  of  a  tubercle. 

The  tubercle  has  no  constant  form,  but  consists  of  one  or  more  multi- 
nuclear  giant  cells,  surrounded  by  an  aggregation  of  smaller  epithelioid 
cells,  about  which  is  a  zone  of  round  lymphoid  cells  the  size  of  leucocytes 
and  smaller  than  epithelioid  cells.  Between  these,  and  continuous  with 
the  irregular  processes  of  the  giant  cells,  is  a  fibrous  reticulum  more 
or  less  prominent. 

Tubercle  bacilli  are  present  in  and  about  these  elements. 

Epithelioid  and  giant  cells,  though  not  peculiar  to  the  tubercle,  are 
more  frequently  found  in  it  than  elsewhere. 

The  many  oval  nuclei  of  the  giant  cells  are  arranged  at  its  circum- 
ference or  at  opposite  poles.  The  epithelioid  cells  may  have  one  or 
two  nuclei;  the  lymphoid  cells,  which  are  smaller  than  the  epithelioid, 
have  each  a  single  relatively  large  nucleus.     A  prominent  feature  of  the 


1 58  PULMONA  R  Y  D1SEA  8ES. 

tubercle  is  its  non-vascularity,  with  a  tendency  to  undergo  early  coagu- 
lation necrosis,  with  coalescence  of  its  cells  into  a  homogeneous,  firm, 
gray  mass,  which  later  becomes  softer,  cheesy,  and  yellow. 

This  caseation  invariably  begins  at  the  centre  of  the  nodule,  and  is 
probably  the  result  of  the  lack  of  nourishment  and  the  specific  action  of 
the  bacilli.  This  tubercle  formation  is  the  same  when  occurring  in  the 
lungs  as  elsewhere;  its  subsequent  course  is,  however,  very  different  and 
varies  in  these  organs  according  to  the  mode  of  infection,  the  resistance 
of  the  tissues,  the  number  of  bacilli  and  possibly  their  virulence.  From 
the  primary  focus,  the  migrating  leucocytes  and  round  cells  carry  the 
tubercle  bacilli  into  the  surrounding  intercellular  and  perivascular 
lymph  spaces  and  into  neighboring  alveoli.  Xew  tubercle  develops  wher- 
ever the  germs  gain  footing,  and,  either  as  a  process  of  inflammatory 
exudation  or  of  cell  proliferation  starting  from  their  walls,  the  adjacent 
air  cells  become  filled  with  fibrin  and  cellular  elements  bearing  the  nox- 
ious principle.  The  walls  of  the  alveoli  and  associated  bronchi  become 
infiltrated  with  round  cells  and  thickened.  The  capillary  plexus  is  de- 
stroyed as  the  process  extends  and  the  tubercles  coalesce,  forming  larger 
foci.  While  extension  proceeds  at  the  circumference,  the  centre  under- 
goes caseation  and  softening,  and  eventually  may  be  partially  discharged 
through  the  bronchi,  leaving  an  irregular,  rapidly  sloughing  cavity  behind. 
By  aspiration  into  other  alveoli  this  discharge  becomes  the  means  of  fur- 
ther lobular  extension.  In  some  instances,  in  addition  to  these  evidences 
of  acute  inflammation,  breaking  down  of  the  lung,  and  wide  dissemi- 
nation of  caseous  foci,  and  more  or  less  extensive  fibroid  thickening  or 
cirrhosis  of  the  peribronchial  and  interlobular  tissues  will  be  observed. 
Such  are  cases  either  of  chronic  inflammation  of  the  lung  upon  which 
tuberculosis  has  supervened,  or  of  primary  pulmonary  tuberculosis  in 
which  the  partially  successful  efforts  of  nature  to  limit  the  disease  have 
resulted  in  connective-tissue  hyperplasia. 

Etiology. — The  predisposing  causes  of  the  disease  are  those  influ- 
ences which  depreciate  the  general  health  of  the  individual  or  which,  by 
diminishing  local  tissue  resistance,  afford  fitting  soil  for  growth  of  the 
bacilli.  Though  the  essential  cause,  the  tubercle  bacillus,  is  probably 
rarely  transmitted  from  mother  to  child,  it  is  reasonable  to  suppose  that 
the  weakness  of  constitution  which  tuberculosis  engenders  in  the  parent 
may  be  inherited  by  the  offspring.  In  so  far,  the  latter  is  a  more  suita- 
ble field  for  infection.  As  reported  by  James  T.  Whittaker,  of  Cincin- 
nati, observations  by  Csokor  [Deutsche  Medizinal-Zeitung,  Berlin,  Jan., 
1892)  and  F.  V.  Birch-Hirschfeld  {Deutsche  medicinische  Wochemchrift, 
Leipzig,  March,  1802)  seem  to  prove  that  the  bacilli  may  be  transmitted 
directly  from  the  mother  to  the  fcetus.  Children  of  those  who  are 
debilitated  by  other  diseases,  by  vicious  habits,  or  by  age  receive  a 
similar  heritage.  The  predisposition  to  tuberculosis  may  also  be  acquired 
by  those  who  are  habitually  subjected  to  improper  hygienic  influences. 


PULMONARY  PHTHISIS.  159 

Poor  or  insufficient  food,  scanty  clothing,  want  of  cleanliness,  impure 
or  damp  and  chilly  air,  and  lack  of  sunshine,  variously  combined,  may 
reduce  the  most  robust  constitution  to  a  condition  as  favorable  to 
phthisis  as  is  the  inherited,  so-called  scrofulous  diathesis.  Prolonged 
lactation,  frequent  child-bearing,  alcoholism,  and  chronic  malaria,  by 
enfeebling  the'  constitution,  also  prepare  the  way  for  tubercular  infec- 
tion. Bronchitis,  pneumonia,  and  other  pulmonary  affections  frequently 
prepare  the  soil  locally  for  the  growth  of  the  specific  germ. 

It  is  now  generally  conceded  that  the  ultimate  cause  of  tuberculosis 
is  the  tubercle  bacillus,  as  first  determined  by  Koch  in  1882.  This  is  a 
slender  rod  varying  in  length  from  one-quarter  to  one-half  the  diameter 
of  a  red  blood-corpuscle ;  it  is  straight  or  curved,  occurring  singly,  in 
chains,  or  in  groups,  and  is  incapable  of  voluntary  motion.  When  prop- 
erly stained,  it  has  a  peculiar  beaded  appearance,  and  if  highly  magnified, 
small  bright  spots  may  be  seen  within  the  rod,  having  the  appearance  of 
spores.  The  bacilli  are  relatively  enduring,  but  grow  outside  the  body 
only  under  the  most  careful  regulation  of  temperature,  nutrient  media, 
and  other  conditions.  Tubercle  bacilli  enter  the  lung  chiefly  through 
the  air  passages,  conveyed  by  particles  of  dried  phthisical  sputum  or 
dust. 

Entrance  may  take  place  through  the  circulation  from  a  primary 
focus  elsewhere.  Such  a  focus  may  in  rare  instances  be  established  by 
the  ingestion  of  tuberculous  meat  or  of  milk  from  a  diseased  animal. 
Chickens  that  are  allowed  to  eat  the  sputum  from  tuberculous  patients 
often  contract  the  disease  and  may  become  a  source  of  infection.  There 
can  be  no  doubt  that  in  a  small  percentage  of  cases  the  disease  is  con- 
tracted by  direct  contagion,  as  in  case  of  those  who  have  nursed  con- 
sumptives long  and  closely.  However,  notwithstanding  the  vast  multi- 
tudes who  yearly  die  of  consumption,  very  few  well-authenticated  cases 
of  direct  contagion,  or  infection  from  ingestion  of  tuberculous  substances, 
can  be  adduced.  The  investigations  of  Henry  P.  Loomis,  of  New  York 
(Eesearches  of  the  Loomis  Laboratory,  No.  1,  p.  75),  show  that  forty 
per  cent  of  the  bodies  of  persons  dying  suddenly  in  general  good  health, 
apparently  perfectly  free  from  tuberculosis,  have  the  bacilli  in  the 
bronchial  glands.  Therefore,  while  it  may  be  admitted  that  Koch's 
bacillus  is  the  ultimate  cause  of  the  disease,  it  appears  impotent  except- 
ing in  the  presence  of  a  favorable  soil  as  furnished  by  those  of  depraved 
constitution. 

Symptomatology. — The  chief  symptoms  of  ordinary  pulmonary 
tuberculosis  are  only  too  well  known,  even  by  the  laity.  Few  there  are 
who  have  not  noticed  among  their  immediate  friends  the  bright  and 
suffused  eye,  hacking  cough,  progressive  emaciation,  haemoptysis  or  pur- 
ulent sputum,  the  hectic  flush,  and  the  night-sweats  of  this  dread  disease. 

The  affection  often  comes  on  insidiously,  with  a  slight  hacking  cough, 
which  does  not  attract  attention  till  the  patient  takes  a  severe  cold,  or  is 


160  PULMONARY  DISEASES. 

taken  down  with  some  acute  disease  from  which  he  does  not  convalesce 
at  the  proper  time;  he  is  then  discovered  to  have  symptoms  of  con- 
sumption. Sometimes,  however,  there  may  have  been  no  hacking  cough 
in  the  beginning;  we  are  often  told  that  the  disease  started  with  a  severe 
cold,  whooping-cough,  measles,  influenza,  typhoid  fever,  intermittent 
fever,  parturition,  or  chronic  affection  of  the  throat  or  bronchial  tubes. 
In  quite  a  large  percentage  of  cases  the  patient  has  been  apparently  in 
perfect  health  until  haemoptysis  has  occurred;  from  this  he  may  have 
perfectly  recovered,  but  not  infrequently  the  symptoms  of  a  grave  dis- 
ease have  steadily  progressed.  Often  there  is  a  history  of  prolonged 
overwork  and  exhaustion  culminating  in  fever,  supposed  to  be  malari- 
ous or  typhoid,  during  which  the  evidences  of  pulmonary  disease  are 
discovered.  In  most  instances  loss  of  weight  occurs  early  in  the  affec- 
tion, depending  generally  upon  loss  of  appetite  or  imperfect  digestion. 
Daily  fever  of  two  or  three  degrees  is  common,  and  a  nearly  uniform 
symptom  is  rapidity  of  the  pulse;  even  while  other  symptoms  may  not 
be  pronounced,  the  pulse  frequently  runs  from  one  hundred  to  one  hun- 
dred and  thirty  per  minute.  The  cough  is  at  first  hacking,  with  little 
or  no  expectoration;  subsequently  the  sputum  may  become  mucous  and 
later  muco-purulent.  Haemoptysis  occurs  in  a  considerable  number  of 
cases,  but  not  in  all;  in  many,  early  in  the  attack;  in  others,  not  until  the 
close  of  the  disease.  A  simple  streaking  of  the  sputum  with  blood 
should  not  be  considered  as  evidence  of  tuberculosis.  In  many  cases 
these  symptoms  gradually  increase  for  six  or  eight  weeks,  and  then 
slowly  subside  until  the  disease  is  arrested,  and  it  may  not  again  become 
active;  but  in  the  majority  who  are  less  fortunate,  as  the  disease  pro- 
gresses there  are  only  periods  of  comparative  health  between  the  attacks 
of  great  depression,  and  each  of  these  latter  is  likely  to  leave  the  patient 
weaker  than  when  it  began,  so  that  he  grows  worse,  although  at  times, 
not  only  the  patient,  but  his  friends  are  encouraged  to  believe  that  he  is 
improving. 

Disorders  of  the  digestive  tract  are  prominent  accompaniments  of 
the  pulmonary  trouble.  Anorexia,  commonly  an  early  symptom,  may 
be  associated  with  nausea  and  vomiting ;  the  latter  may  be  due  to  the 
severity  of  the  cough.  Gastric  pains,  which  are  often  present,  may  be 
reflex  or  may  be  dependent  upon  an  inflamed  condition  of  the  mucous 
membrane  of  the  stomach.  Diarrhoea  is  frequently  very  troublesome  in 
advanced  cases,  and  is  not  uncommon  at  any  period  of  the  disease. 
Eapid  emaciation,  proportioned  to  the  acuteness  of  the  affection,  is  a 
natural  consequent  of  continued  fever  and  anorexia,  and  attendant  mal- 
nutrition may  be  aggravated  by  haemoptysis  or  a  chronic  colliquative 
diarrhcea.  In  many  instances  tubercular  patients  are  hopeful  to  the 
end,  though  this  is  less  common  than  is  generally  supposed.  In  the 
later  stages  of  the  disease,  cerebral  anaemia  or  possibly  tubercular  changes 
in  the  brain  itself,  or  the  sympathetic  effects  of  imperfect  digestion 
affect  the  mental  condition,  causing   irritability,  fretfulness,   cerebral 


PULMONARY  PHTHISIS.  161 

fatigue  upon  mental  exertion,  and  finally,  in  some  cases,  hallucinations 
or  fixed  delirium ;  though  commonly  the  mind  remains  clear  to  the  last. 

The  signs  differ  in  various  stages  of  the  affection,  the  most  impor- 
tant being :  diminished  movement  and  sinking  in  of  the  chest  walls  in 
the  infra-clavicular  region,  with  dulness  on  percussion;  and  at  an  early 
stage,  feeble  respiration,  or  subcrepitant  rales  confined  to  one  apex, 
followed  by  broncho-vesicular  respiration,  exaggerated  vocal  resonance, 
metallic  rales,  and  the  signs  of  cavities. 

Phthisis  is  generally  described  as  having  three  stages,  but  these  run 
imperceptibly  into  each  other,  so  that  the  signs  of  two  or  of  all  of  them 
are  likely  to  be  combined  at  one  time  in  the  same  individual.  The 
stages,  therefore,  cannot  be  sharply  delineated,  and  I  think  an  attempt 
to  describe  the  signs  of  each  separately  would  only  lead  to  confusion. 

The  stages  of  phthisis  consist  of :  first,  the  incipient  stage ;  second, 
the  stage  of  more  complete  deposition,  occasioning  consolidation  and  re- 
traction; and  third,  the  stage  of  softening  with  breaking  down  of  lung 
tissue  and  the  formation  of  cavities.  The  pulmonary  lesions  occur  with 
about  equal  frequency  on  the  right  and  on  the  left  side  of  the  chest,  and 
almost  always  they  are  to  be  found  at  the  apex  of  the  lung. 

Inspection  and  mensuration  yield  no  signs  in  the  early  stage  of  this 
disease,  except  increased  rapidity  of  the  respiratory  movements.  After 
a  few  weeks,  in  the  second  stage,  in  addition  to  the  rapid  respirations, 
we  observe  more  or  less  loss  of  motion,  with  sinking  in  of  the  chest 
wall  over  the  affected  organ,  especially  during  deep  inspiration.  In 
the  last  stage  of  the  disease,  there  is  marked  emaciation,  with  promi- 
nence of  the  clavicles  due  to  the  sinking  in  of  the  tissues  above  and 
below  them;  loss  of  motion  becomes  more  distinct,  and  there  is  depres- 
sion of  the  chest  walls,  usually  in  the  infra -clavicular  region. 

Exceptional. — la  exceptional  cases,  cavities  may  exist  in  the  apices  of  the 
lungs  without  any  considerable  depression  of  the  chest  walls  or  diminution  in 
their  movements. 

Early,  palpation  furnishes  no  signs.  As  soon  as  any  considerable 
amount  of  consolidation  has  taken  place,  the  vocal  fremitus  is  apt  to  be 
increased,  but  this  sign  is  variable,  and  therefore  unreliable.  Sometimes 
gurgling  fremitus  is  detected  over  superficial  cavities. 

Exceptional. — Shrinking  of  the  affected  lung  may  drag  the  heart  a  short  dis- 
tance from  its  normal  position,  as  indicated  by  the  site  of  its  apex  beat.  The 
formation  of  a  large  cavity  occasionally  causes  bulging  of  the  portion  of  the 
chest  which  was  formerly  depressed. 

On  percussion  in  the  first  stage  of  this  disease,  there  is  slight  dulness 
if  the  superficial  portions  of  the  lung  be  affected ;  but  if  only  the  deeper 
structures  are  involved,  this  sign  may  be  absent. 

Dulness,  when  slight,  is  best  obtained  with  the  patient's  mouth  open, 
and  the  difference  in  the  resonance  of  the  two  sides  can  be  most  easily 
recognized  at  the  end  of  a  full  inspiration. 
ii 


162  PULMONARY  DISEASES. 

The  late  H.  A.  Johnson,  of  Chicago,  told  me  that  he  sometimes  obtained  ex- 
cellent results,  in  obscure  cases,  by  listening-  with  the  ordinary  binaural  stetho- 
scope, the  chest  piece  of  which  was  held  by  the  patient  about  two  inches  in  front 
of  his  open  mouth  while  percussion  was  being  made  on  the  chest. 

In  this  connection,  it  must  be  constantly  borne  in  mind  that  mod- 
erate dullness  is  frequently  a  normal  sign  over  the  right  apex,  and  that 
other  diseases  than  phthisis,  as,  for  example,  bronchitis  and  circum- 
scribed ]:meumonia,  not  infrequently  cause  temporary  dulness  in  the 
infra- clavicular  region. 

Dulness  over  the  left  apex,  even  though  slight,  is  always  abnormal, 
and,  when  persistent,  is  nearly  always  a  sign  of  phthisis.  Marked  dul- 
ness, if  persistent,  has  the  same  significance  when  found  over  the  right 
apex.  This  sign  is  sometimes  found  behind  when  it  cannot  be  detected 
in  front.  It  is  frequently  present  in  the  supra-clavicular  or  clavicular 
region  when  it  cannot  be  obtained  below  the  clavicle. 

Exceptional. — In  the  first  stage  of  phthisis  the  resonance  is  sometimes 
Tesiculo-tympanitic,  on  account  of  secondary  circumscribed  emphysema. 

Consolidation  of  the  deeper  portions  of  the  lung  may  cause  no  dulness  upon 
ordinary  percussion  if  healthy  lung  tissue  intervene  between  it  and  the  surface. 
In  forcible  percussion  a  small  amount  of  consolidation  at  the  surface  of  the  lung 
may  be  overlooked  in  consequence  of  the  intense  resonance  from  the  deeper 
tissues. 

It  should  be  remembered,  in  estimating  the  amount  of  phthisical  con- 
solidation, that  the  degree  of  dulness  and  its  area  may  be  due  to  the 
temporary  consolidation  of  circumscribed  pneumonia.  The  extent  of 
phthisical  consolidation  in  such  cases  can  only  be  ascertained  after  the 
inflammatory  product  has  been  absorbed. 

In  the  second  stage  of  phthisis,  dulness  becomes  very  marked,  and 
gradually  extends  over  a  wider  area,  owing  to  progressive  pulmonary 
consolidation ;  up  to  this  time,  dulness  is  almost  universally  confined 
to  one  side.  At  the  same  time,  tubular — or,  according  to  Flint,  tym- 
panitic— resonance  may  be  caused  by  the  bronchial  tubes  or  the 
trachea,  especially  when  percussion  is  made  near  the  borders  of  the  upper 
part  of  the  sternum. 

Exceptional. — In  this,  as  in  the  first  stage,  vesiculotympanitic  resonance 
may  be  obtained  in  rare  instances. 

In  the  third  stage,  dulness  is  obtained  over  the  affected  lung,  unless 
cavities  of  considerable  size  exist  near  the  surface.  In  this  case,  reso- 
nance over  a  limited  portion,  surrounded  by  dulness  and  corresponding 
to  the  cavity,  may  be  tympanitic,  amphoric,  or  cracked -pot  in  char- 
acter. Sometimes  early  in  the  morning,  dulness  or  flatness  may  be  ob- 
tained over  a  cavity,  owing  to  its  being  filled  with  secretions,  which  will 
give  place,  after  free  expectoration,  to  the  signs  of  a  vomica.  In  this 
stage,  or  in  the  latter  part  of  the  second  stage,  dulness  nearly  always 


DISEASES  OF  THE  CHEST,  THROAT,   AND   NASAL   CAV1TIES.-INGALS. 


Fig.  29— Tubercle  Bacilli  in  Sputum. 


The   bacilli,  stained  red,  in  the  larger  plate,  are  magnified  about  1,000  diameters  ;  those  in  the 
smaller  plate  about  3,500   diameters. 


PULMONARY  PHTHISIS.  163 

appears  at  the  apex  of  the  opposite  lung,  where  it  can  be  detected  by 
conrparing  the  resonance  over  the  diseased  structure  with  that  below  the 
second  or  third  rib. 

Among  the  early  signs  of  this  disease  to  be  detected  by  auscultation 
are  feeble  or  cog-wheel  respiration,  with  subcrepitant  rales,  limited 
to  a  small  portion  of  the  apex  of  one  lung.  Occasionally  the  mucous 
click  or  a  few  crepitant  or  sibilant  rales,  or  crumpling  or  friction  sounds, 
may  be  heard  in  the  same  locality.  Broncho-vesicular  respiration  is 
obtained  a  little  later.  The  heart-sounds  are  heard  with  abnormal  in- 
tensity over  the  affected  lung;  if  the  consolidation  be  upon  the  right 
side,  the  first  sound  of  the  heart  will  be  most  distinct;  if  upon  the  left, 
the  second  sound  is  more  intense  than  the  first. 

In  the  first  stage,  the  exaggerated  bronchial  whisper  is  a  sign  of 
considerable  value,  and  exaggerated  vocal  resonance  can  usually  be  ob- 
tained. 

At  a  later  period,  in  the  second  stage,  broncho-vesicular  respiration 
becomes  distinct,  the  respiratory  sounds  are  harsh  and  tubular  in  qual- 
ity, and  the  expiratory  murmur  is  prolonged  and  high-pitched.  There 
are  also  large  and  small,  moist,  crackling,  or  metallic  rales,  which  are 
often  sticky  in  character,  and  not  affected  by  coughing.  Friction  sounds 
are  often  present,  due  to  circumscribed  pleuritis,  caused  by  the  tubercu- 
lar deposit  in  the  pleura.  In  a  few  cases,  subcrepitant  or  sibilant,  and 
occasionally  sonorous,  rales  may  still  be  heard  in  the  second  stage,  lim- 
ited to  a  small  space  over  the  affected  tissue.  Kales  are  generally  most 
abundant  in  the  morning,  before  free  expectoration  has  taken  place. 
Vocal  resonance,  with  the  whispered  or  the  loud  voice,  is  now  exagger- 
ated or  bronchophonic.  In  some  cases,  when  the  consolidated  lung  im- 
mediately surrounds  a  large  bronchial  tube,  pectoriloquy  may  be  ob- 
tained. During  the  latter  part  of  this  stage,  the  signs  of  incipient 
phthisis  usually  appear  at  the  apex  of  the  opposite  lung. 

In  the  third  stage,  when  cavities  have  formed  in  the  lungs,  if  they 
are  empty  and  are  connected  with  a  bronchial  tube,  cavernous  or 
broncho-cavernous  respiration  will  be  detected.  True  cavernous  respi- 
ration, of  a  soft  blowing  or  puffing  character,  and  of  low  pitch,  is  one  of 
the  very  rare  signs  of-  phthisis.  Broncho-cavernous  respiration,  having 
much  of  the  bronchial  element,  still  with  a  hollow  quality  strongly 
suggestive  of  a  cavity,  is  heard  in  nearly  every  case.  Amphoric  respira- 
tion is  found  in  exceptional  instances  only.  Associated  with  these  signs 
we  usually  hear  numerous  rales  and  gurgles  with  bronchophony,  pec- 
toriloquy, or  cavernous  voice,  and  occasionally  metallic  tinkling  and 
amphoric  voice.     The  signs  of  the  second  stage  also  are  generally  present. 

If  cavities  are  filled  with  fluid,  none  of  the  ordinary  signs  of  the 
third  stage  may  be  obtained.  Small  cavities  located  in  the  deeper  por- 
tions of  the  lungs  are  not  easily  detected. 

In  advanced  phthisis,  we  may  reasonably  conclude  that  a  cavity  ex- 


164  PULMONARY  DISEASES. 

ists  whenever  the  respiratory  and  vocal  sounds  over  a  small  space,  and 
limited  to  it,  are  peculiarly  intense  and  bronchial  in  character,  and  asso- 
ciated with  metallic  rales. 

DIAGNOSIS. — Pulmonary  tuberculosis  is  to  be  distinguished  from 
chronic  laryngitis,  chronic  bronchitis,  pleurisy,  chronic  pneumonia,  syph- 
ilis of  the  lung,  cancer  of  the  lung,  and  other  intra-thoracic  tumors.  Its 
differential  diagnosis  from  these  affections  will  be  found  under  their 
respective  titles.  The  diagnosis  will  depend  upon  the  history,  symp- 
toms, and  physical  signs  just  mentioned,  and  upon  the  discovery  of 
tubercle  bacilli  in  the  sputum.  The  presence  of  these  bacilli  in  any 
number  is  always  indicative  of  tuberculosis,  and  in  most  cases  their 
abundance  is  in  proportion  to  the  severity  of  the  disease  (Clinical  Diag- 
nosis, Jaksch);  their  absence  from  the  sputum  is  not  in  every  case  posi- 
tive evidence  that  the  disease  does  not  exist. 

Elastic  fibres  in  the  sputum,  though  not  peculiar  to  tuberculosis,  are  indica- 
tive of  pulmonary  ulceration. 

To  Stain  Tubercle  Bacilli  is  Sputum. — Many  modifications  of 
the  Koch-Ehrlich  method  for  staining  tubercle  bacilli  have  been  sug- 
gested. 

Ziehl's  solution,  which  remains  good  for  many  months,  is  now  com- 
monly employed  instead  of  the  aniline  preparations.  It  consists  of  dis- 
tilled water  one  hundred  parts,  alcohol  ten,  carbolic  acid  five,  fuchsin 
one  part.  The  procedure  which  I  have  found  most  convenient  is  as 
follows : 

(1)  Examine  the  sputum  on  a  plate  of  glass  against  a  black  back- 
ground. 

(2)  Pick  out  a  very  small  quantity  of  nummulated  purulent  sputum. 

A  platinum  needle  fixed  in  a  glass  rod  is  most  suitable  for  this  purpose ;  it 
should  be  sterilized  in  the  flame  of  an  alcohol  lamp  or  Buusen  burner  before 
usin^r. 

(3)  Spread  the  selected  sputum,  in  a  thin  layer,  evenly  between  two 
glass  slides,  by  drawing  them  successively  one  upon  the  other. 

(4)  Dry  in  the  air  or  high  above  the  flame  of  an  alcohol  lamp  or 
Bunsen  burner. 

(5)  Fix  the  albumin  by  passing  the  slide  several  times  through  the 
flame  with  the  film  upward. 

(6)  Pour  about  twenty  minims  of  Ziehl's  solution  upon  the  slide 
thus  prepared,  and  heat  over  the  flame  till  it  steams. 

(?)  Let  it  stand  for  thirty  seconds,  or  longer:  then  wash  in  clean 
water. 

(8)  Decolorize  to  a  faint  pink  color  with  a  two  or  three  per  cent 
solution  of  sulphuric  or  any  of  the  mineral  acids. 

This  can  be  done  best  by  dipping  the  slide  for  a  few  seconds  in  the 


ACUTE  MILIARY  TUBERCULOSIS.  165 

acid  solution,  washing  directly  in  water,  and  holding  it  up  to  the  light 
for  inspection,  repeating  the  operation  until  the  faint  pink  color  is  ob- 
tained. 

(9)  Counterstain  with  a  two  or  three  per  cent  watery  solution  of 
methylene  blue,  which  is  merely  poured  upon  the  slide  and  left  from 
thirty  to  sixty  seconds  with  or  without  heating.  Methylene  blue,  if  a 
good  article,  is  readily  soluble  in  water.  Two  or  three  grains  of  chloral 
may  be  added  to  the  ounce  of  methylene  solution  to  prevent  decompo- 
sition. 

(10)  Wash  in  clean  water. 

(11)  Dry,  and  mount  with  cover-glass  in  glycerine  or  permanently  in 
balsam,  and  examine;  or  dry  and  examine  directly  without  a  cover- 
glass,  with  a  one-twelfth  oil  immersion  lens.  This  lens  with  a  No.  4 
eyepiece  (Zeiss)  magnifies  about  a  thousand  diameters  and  shows  the 
bacilli  as  represented  in  Fig.  29,  which  was  drawn  for  me  by  Hene- 
age  Gibbes,  of  the  University  of  Michigan. 

The  bacilli  may  be  seen  distinctly  with  lower  powers,  but  their  detec- 
tion is  much  more  easily  and  speedily  accomplished  by  this  lens. 

Thus  prepared,  the  small  beaded  bacilli  appear  red,  while  all  other 
micro-organisms,  cells,  albumin,  and  fibres  are  stained  blue.  The  only 
other  micro-organism  yet  discovered  which  closely  resembles  the  tuber- 
cle bacillus  in  form,  size,  and  manner  of  staining  is  the  bacillus  of  lep- 
rosy, which  differs  from  the  tubercle  bacillus  in  taking  the  watery 
anilin  stains  equally  as  well  as  other  bacteria  (Linsley's  translation 
of  Fraenkel's  Bacteriology,  page  231). 

Discovery  of  the  bacilli  may  sometimes  be  facilitated  by  thoroughly 
stirring,  and  boiling  in  a  large  test-tube,  about  3  i.  of  the  sputum  with 
3  vi.  of  a  solution  of  caustic  soda,  3  parts  to  1,000,  until  it  forms  a 
thin  mass.  This  should  be  allowed  to  settle  twenty-four  hours,  when 
the  sediment, which  carries  down  the  bacilli,  should  be  examined. 


ACUTE   MILIARY   TUBERCULOSIS. 

Miliary  tuberculosis  of  the  lungs  is  a  part  of  a  general  disease; 
though  all  the  viscera,  and  especially  the  peritoneum,  pleura,  and  men- 
inges, may  be  involved,  the  lungs  are  the  chief  seat  of  deposit. 

ANATOMICAL  AND  PATHOLOGICAL  CHARACTERISTICS. — Small  nodules 

the  size  of  a  pin-head  are  observed  scattered  over  the  pleura  and  dissem- 
inated throughout  the  affected  lungs,  which  are  usually  congested  and 
cedematous.  To  the  unaided  eye  these  tubercles  appear  sharply  defined. 
Microscopically  the  outer  zone  of  lymphoid  cells  is  seen  to  merge  grad- 
ually into  the  surrounding  lung.  The  air  cells  contain  to  some  degree 
the  elements  of  exudation. 

Etiology. — The  immediate  focus  of  general  infection  may  be  in  any 


166 


PULMONARY  DISEASES. 


organ,  bones,  joints,  or  in  the  urinary  tract,  but  usually  it  is  in  the 
lungs  or  lymphatic  glands. 

Ulceration  into  a  lymphatic  trunk  is  followed  by  entrance  of  bacilli 
into  the  circulation  and  more  or  less  extensive  infection  of  other  parts. 

Symptom atology. — The  general  symptoms  are  very  like  those  of 
typhoid  fever,  though  the  temperature  is  frequently  highest  in  the 
morning,  ranging  between  103°  and  105°  F.,  and  occasionally  going  up 
to  10T°  F.  Prostration  is  very  early  and  marked.  Involvement  of  the 
meninges  gives  intense  headache,  vomiting,  opisthotonos,  delirium,  and 
ocular  disturbance.  The  pulmonary  symptoms  are  not  characteristic, 
but  cough  is  usually  present  and  expectoration,  if  present,  is  frothy  in- 
stead of  muco-purulent.  Xo  tubercle  bacilli  are  present  in  the  sputum, 
unless  a  localized  tuberculosis  of  the  lung  has  existed  before  occurrence 
of  the  miliary  form  of  the  disease. 

Acute  miliary  tuberculosis  is  attended  by  no  physical  signs  unless 
the  mucous  membrane  lining  the  air  passages  is  involved,  and  then 
there  are  no  signs  except  those  of  bronchitis.  The  diagnosis  in  such 
cases  must  rest  upon  the  history  and  symptoms,  and  the  exclusion  of 
other  pulmonary  affections. 

Diagnosis. — Discrimination  between  the  various  forms  of  phthisis 
is  often  attended  with  more  or  less  uncertainty.  The  principal  features 
of  value  in  distinguishing  between  them  may  be  seen  in  the  following 
table  •• 


Fibroid  and  other  vari-    Chronic  tuberculosis    Acute  miliary  tubercu- 
eties  of  simple  inflam-       or     the     ordinary       losis. 
matory  phthisis.  form  of  phthisis. 


The  constitutional  symp- 
toms come  on  slowly,  and 
are  less  severe  than  would 
naturally  be  expected  from 
the  condition  of  the  lung,  as 
indicated  by  physical  signs. 


Hixtory. 
The  constitutional 
symptoms  come  on  more 
rapidly,  and  are  graver 
than  would  be  expected 
from  the  physical  signs. 


The  disease  is  ushered  in 
with  chills  and  fever  with- 
out complete  remissions, 
and  there  is  rapid  acces- 
sion of  grave  constitutional 
symptoms,  which  cannot 
bu  accounted  for  by  the 
bronchitis,  signs  of  which 
are  the  only  ones  to  be  ob- 
tained. 


Symptoms. 

The   fever   is    intermit-  The  fever  more  contin-        Fever    remittent,     tem- 

tent,  with  an  afternoon  or  uous,  with  nearly  con-    perature  often  highest  in 

evening  elevation  in  tern-  stant  elevation  of  tern-    the  morning,  varying  from 

perature   of    from    one  to  perature,      but      less    103:  to  105'  or  even  107  F. 

two  degrees.  marked  exacerbations. 

Diarrhoea  not  common.  Diarrhoea  usual. 


FIBROID  PHTHISIS. 


167 


Fibroid  and  other  vari- 
eties of  simple  inflam- 
matory PHTHISIS. 


Rapid  respiration,  and 
signs  of  consolidation  upon 
palpation,  percussion,  and 
auscultation,  usually  ex- 
tending over  a  large  part 
of  the  lung. 

No  tubercle  bacilli  in 
sputum. 


Chronic  tuberculosis 
or  the  ordinary 
form  of  phthisis. 

Signs. 

Rapid  respiration, 
physical  signs  of  consol- 
idation less  marked  and 
limited  to  a  smaller  area 
than  in  the  preceding 
variety. 

Tuberclebacilli  inspu- 
tum. 


Acute  miliary  tubercu- 
losis. 


Rapid  respiration,  with 
usually  the  signs  of  bron- 
chitis, and  ordinarily  no 
signs  of  consolidation,  but 
occasionally  slight  dul- 
ness. 

Usually  no  tubercle  ba- 
cilli in  sputum. 


FIBROID    PHTHISIS. 

Synonyms. — Fibroid  degeneration  of  the  lungs;  fibrosis;  chronic 
pneumonia;  interstitial  pneumonia;  cirrhosis,  or  scirrhus  of  the  lungs; 
induration  of  the  lungs. 

Fibroid  phthisis  is  a  chronic  inflammatory  affection  characterized 
by  comparatively  slow  progress,  though  in  the  majority  of  cases  it  finally 
terminates  in  tuberculosis.  As  compared  with  the  ordinary  form  of 
consumption,  the  symptoms  are  slight  in  proportion  to  the  amount  of 
lung  tissue  involved. 

Anatomical  and  Pathological  Characteristics. — The  chief  ana- 
tomical changes  consist  of  hyperplasia  of  the  interalveolar,  interlobular, 
and  peribronchial  structures,  which  encroach  upon  the  air  passages  and 
blood-vessels,  correspondingly  diminishing  their  capacity ;  this  encroach- 
ment is  subsequently  increased  by  the  contraction  of  the  newly  formed 
elements.  There  is  little  or  no  exudation  into  the  air  cells.  The  dis- 
ease may  involve  a  part  or  the  whole  of  one  lung,  or  both  lungs  may  be 
affected,  though  commonly  it  is  confined  to  one  side  of  the  chest 
throughout  the  greater  portion  of  its  course. 

Inspection  of  the  affected  organ  reveals  in  most  cases  more  or  less 
extensive  adhesions  of  the  overlying  pleura,  and  often  extensive  thick- 
ening of  the  latter  membrane,  especially  when  the  disease  has  resulted 
from  pleurisy. 

Occasionally  fluid  is  found  in  circumscribed  pockets  of  the  partially 
obliterated  pleural  cavity.  The  thickened  pleura  may  present  very 
much  the  appearance  and  density  of  fibro-cartilage.  When  the  process 
is  general,  an  entire  lung  may  be  found  shrunken  to  one-tenth  of  its 
normal  size.  The  color  varies  from  a  dark  red  to  a  bluish-gray,  marbled 
with  black  and  streaked  with  lighter  lines. 

When  localized,  the  shrunken,  cirrhosed  area  contrasts  strongly 
with  the  adjacent  normal  or  emphysematous  lung  tissue.  This  part  is 
abnormally  heavy,  and  sinks  readily  in  water,  and  when  pressed  yields 
but  little  fluid  from  its  cut  surface.     In  advanced  cases,  the  tissue  is 


1  68  PULMONA  R  Y  DISEASES. 

so  firm  that  upon  section  the  knife  grates  as  in  cutting  cartilage.  The 
cut  surface  is  of  a  dark  gray  or  blackish  color,  intersected  by  yellowish- 
white  bands,  and  mottled  with  lighter  circles  marking  the  position  of 
obliterated  vessels  and  tubes. 

As  the  process  advances,  and  contraction  of  the  new  tissue  occurs, 
many  of  the  air  cells  become  destroyed,  although  here  and  there  islets  of 
normal  or  emphysematous  vesicles  may  still  remain.  During  the  pro- 
cess, many  of  the  bronchial  arteries,  together  with  numerous  branches  of 
the  pulmonary  artery  are  obliterated ;  and  as  a  result  of  the  process  of 
contraction,  here  and  there  dilatation  occurs  in  the  bronchial  tubes;  and 
bronchiectatic  cavities  are  found,  lined  by  dark  red,  thickened  mucous 
membrane,  and  containing  purulent  fluid,  or  cheesy  debris.  These  cavi- 
ties may  also  be  the  seat  of  ulceration  or  gangrene  and  vary  from  half 
an  inch  to  two  inches  in  diameter.  The  bronchial  glands  are  frequently 
enlarged,  and  ultimately  these  and  the  cirrhotic  lung  tissue,  in  many 
cases,  become  the  seat  of  tuberculosis. 

When  the  affection  is  confined  to  one  lung,  the  opposite  organ  may 
be  functionally  enlarged  or  may  become  emphysematous,  and  not  infre- 
quently at  the  autopsy  this  lung  will  be  found  the  seat  of  bronchitis  or 
acute  croupous  pneumonia  which  has  been  the  immediate  cause  of  death. 
In  marked  cases  the  heart  is  displaced  toward  the  affected  organ  by 
traction  of  the  contracting  tissues,  and  its  right  cavities  are  usually 
dilated,  while  their  walls  are  hypertrophied  as  the  result  of  obstruction 
to  the  passage  of  venous  blood  through  the  lung. 

Etiology. —  The  disease  occurs  most  commonly  in  males  between 
fifteen  and  forty  years  of  age,  and  is  generally  the  result  of  local  causes 
having  little  or  no  dependence  upon  diathesis.  Catarrhal  pneumonia 
and  pleurisy  are  among  the  most  frequent  causes  of  the  disease,  but  it 
may  result  from  chronic  bronchitis  or  acute  croupous  pneumonia;  cir- 
cumscribed induration  is  also  a  common  result  of  arrested  pulmonary 
tuberculosis. 

Symptomatology. — The  progress  of  fibroid  phthisis  is  not  so  rapid 
aB  that  of  the  common  form  of  consumption;  but  its  symptoms  and 
signs  are  usually  much  the  same  excepting  that  the  symptoms  do  not 
appear  commensurate  with  the  pulmonary  lesions,  as  indicated  by  the 
physical  signs. 

As  a  rule,  the  disease  is  chronic  from  its  inception,  although  its  de- 
velopment may  date  from  an  attack  of  pleurisy,  pneumonia,  or  bron- 
chitis. The  origin  is  often  obscure,  and  the  history  is  similar  to  that  of 
chronic  bronchitis,  with  frequent  exacerbations.  Dyspnoea,  though  often 
absent  or  moderate,  increases  with  the  advance  of  the  disease,  and  is 
subject  to  exacerbations,  during  which  the  difficulty  of  breathing  may 
be  experienced  for  several  days.  During  the  latter  portion  of  the  dis- 
ease dyspnoea  is  constant  upon  any  exertion,  and  eventually  becomes  very 
great,  even  though  the  patient  is  quiet.     Cough  is  a  common  symptom, 


FIBROID  PHTHISIS.  169 

though  it  varies  much  in  different  cases,  and  different  periods  of  the 
same  case.  It  is  increased  by  recurrent  attacks  of  bronchitis,  and  is 
generally  worse  during  the  winter  months.  When  bronchiectasis  exists, 
the  cough  is  likely  to  be  paroxysmal,  especially  severe  in  the  morning, 
and  accompanied  by  a  profuse,  fetid  expectoration,  after  which  relief 
may  be  experienced  for  several  hours.  Vomiting  often  follows  these 
paroxysms  of  coughing.  The  sputa  may  be  scanty,  and  viscid,  but  when 
dilatation  of  the  bronchial  tubes  has  taken  place,  it  is  generally  copious, 
sometimes  amounting  to  two  or  three  pints  in  the  twenty-four  hours. 
It  may  consist  of  mucus  or  muco-pus,  and  is  usually  of  a  yellowish  or 
greenish-yellow  color. 

Haemoptysis  is  not  uncommon,  even  in  the  absence  of  tuberculosis. 
During  the  greater  portion  of  the  disease  the  appetite  usually  remains 
good,  and  consequently  the  strength  may  be  fair  and  emaciation  gradual 
unless  tuberculosis  supervenes.  In  well-marked  cases  the  signs  are  tol- 
erably distinctive. 

Inspection  shows  flattening  of  the  chest  wall  over  the  affected  part, 
and  depression  of  the  shoulder  may  be  observed. 

On  palpation,  vocal  fremitus  is  exaggerated.  The  heart  is  dislocated 
more  or  less  toward  the  affected  side,  as  shown  by  the  position  of  the 
apex-beat. 

Percussion  gives  dulness  over  the  affected  side  and  exaggerated  res- 
onance on  the  sound  side,  which  sometimes  extends,  in  consequence  of 
the  distention  of  the  healthy  lung,  from  two  to  four  inches  beyond  the 
median  line  toward  the  affected  side. 

Auscultation  gives  bronchial  breathing  and  bronchophony,  with  or 
without  bronchial  rales.  Subcrepitant  rales  are,  however,  commonly 
present.     The  vesicular  murmur  is  feeble  or  absent. 

The  diagnosis,  prognosis,  and  treatment  of  fibroid  phthisis  will  be 
considered  with  pulmonary  tuberculosis,  though  we  may  here  state  that, 
during  the  earlier  part  of  the  disease,  the  treatment  indicated  is  essen- 
tially the  same  as  that  for  chronic  bronchitis. 

PROGNOSIS     IX   THE    VARIOUS   FORMS    OF    PULMONARY   PHTHISIS. — 

Acute  miliary  tuberculosis  frequently  runs  its  course  within  three  to  six 
weeks,  and  seldom  extends  over  three  months.  Chronic  tuberculosis 
may  terminate  fatally  within  five  or  six  months,  but  it  often  lasts  for 
two  or  three  years,  the  average  duration  being  about  eighteen  months. 
The  records  of  autopsies  show  that  about  twenty-five  per  cent  of  the 
patients  dying  in  hospitals  as  a  result  of  accidents  and  acute  disease, 
have  cicatrices  in  the  apices  of  the  lungs  resulting  from  old  inflamma- 
tions, probably  of  tubercular  origin;  and  experience  has  shown  that  quite 
a  large  percentage  of  patients  suffering  from  well-marked  though  not 
extensive  tuberculosis  recover.  While  I  am  not  able  to  fortify  my  im- 
pression by  statistics,  I  believe  that,  all  told,  about  thirty-three  per  cent 


170  PULMONARY  DISEASES. 

recover  under  ordinary  conditions,  and  I  think  that  patients  sent  early 
to  high  altitudes  and  a  dry  atmosphere  have  their  chances  of  recovery 
increased  fully  fifty  per  cent.  Where  the  disease  is  so  extensive  at  the 
apex  of  one  lung  that  the  signs  may  be  recognized  below  the  second  rib, 
perfect  recovery,  so  that  no  signs  whatever  can  be  detected,  seldom 
occurs,  but  the  disease  not  infrequently  becomes  arrested,  the  cough  and 
all  other  symptoms  disappearing,  the  evidence  given  by  a  scar  in  the 
lung  being  all  that  can  be  detected  on  careful  physical  examination. 
When  the  disease  has  extended  as  low  as  the  fourth  rib,  there  are  a 
few  cases  in  whom  it  may  be  arrested,  provided  they  have  the  best 
hygienic  surroundings;  but  after  the  whole  of  the  upper  lobe  of  one 
lung  and  possibly  a  small  part  of  the  lower  lobe,  together  with  the  apex 
of  the  opposite  lung,  have  become  involved,  it  is  very  rare  that  much 
improvement  takes  place,  though  even  when  these  conditions  exist 
and  after  cavities  of  considerable  size  have  been  formed,  Ave  occasion- 
ally find  the  disease  arrested,  so  that  the  patient  may  live  for  many 
years. 

Usually  fibroid  phthisis  continues  four  or  five  years,  sometimes 
longer,  but  finally  it  eventuates  in  tuberculosis,  terminating  in  much 
the  same  way  as  the  ordinary  form  of  this  disease.  Usually  death  results 
from  asthenia,  occasionally  from  heart  failure,  and  in  a  small  percentage 
of  cases  from  hemorrhage.  Out  of  over  six  hundred  private  cases  of 
which  I  have  records,  but  five  are  known  to  have  died  from  hemorrhage. 
Generally  the  approach  of  death  is  indicated  by  rapid  extension  of  the 
disease  and  speedy  failure  of  the  vital  powers. 

After  decided  swelling  of  the  feet  occurs,  patients  seldom  live  more 
than  five  or  six  weeks;  they  usually  succumb  in  from  three  to  eight 
weeks,  when  the  strength  has  so  far  failed  that  they  are  unable  to  leave 
the  bed,  though  sometimes  life  is  more  prolonged.  Two  or  three  days 
before  the  fatal  issue,  many  consumptives  become  so  feeble  that  the 
sputum  is  raised  with  great  difficulty;  cough  becomes  less  and  less  fre- 
quent, and  may  finally  cease  a  few  hours  before  death. 

Treatment  of  the  Various  Forms  of  Pulmonary  Phthisis. — 
Having  considered  some  of  the  special  forms  which  pulmonary  phthisis 
assumes,  we  may  discuss  more  fully  the  general  treatment. 

As  a  matter  of  prophylaxis,  healthy  persons  should  not  occupy  the 
same  apartment  with  consumptives,  and  great  care  should  be  exercised 
to  prevent  the  drying  of  tubercular  sputum,  and  to  thoroughly  disinfect 
or  destroy  it.  The  treatment  of  acute  tuberculosis  can  seldom  if  ever 
be  more  than  palliative,  though  it  is  proper  to  use  the  same  remedies 
that  are  recommended  for  more  protracted  forms  of  the  disease. 

For  chronic  tuberculosis  the  most  important  remedies  are  alcohol, 
malt  preparations,  cod-liver  oil,  calcium  chloride,  quinine,  iron,  iodine, 
guaiacol,  and  oil  of  cloves,  with  proper  climate. 


TREATMENT  OF  PULMONARY  PHTHISIS.  171 

Alcohol  should  be  used  in  large  quantities,  as  much  as  can  be  borne 
without  affecting  the  head,  providing  it  does  not  derange  digestion  or 
cause  elevation  of  temperature. 

Cod-liver  oil  should  be  given  to  those  patients  who  can  take  it  with- 
out disturbing  their  digestion,  in  doses  of  a  teaspoonful  to  a  tablespoon- 
ful  three  times  a  day,  always  commencing  with  small  doses.  Whenever 
cod-liver  oil  cannot  be  borne,  it  may  be  substituted  by  cream  or  prepara- 
tions of  malt.  The  latter  are  usually  preferable  to  oil  during  warm 
weather. 

Calcium  chloride  is  a  remedy  of  undoubted  value  in  many  cases.  I 
have  found  it  more  serviceable  than  the  calcium  or  sodium  hypophos- 
phites.  The  dose  is  from  ten  to  twenty  or  even  thirty  grains  three 
times  a  day.  It  may  be  dissolved  in  a  small  quantity  of  water,  and  com- 
bined with  the  cod-liver  oil.  By  shaking  the  bottle  before  the  medicine 
is  poured  out,  the  two  can  be  sufficiently  mixed.  It  may  be  added  to  an 
emulsion  of  cod-liver  oil  prepared  as  directed  (Form.  3). 

Quinine  is  the  best  remedy  for  relieving  hectic  fever.  It  will  usu- 
ally prove  efficient  when  given  in  the  same  manner  as  for  intermittent 
fever.  It  acts  most  promptly  when  given  in  one  or  two  large  doses  a 
couple  of  hours  before  the  fever  is  expected.  It  should  be  continued  in 
this  manner  until  the  temperature  falls  or  cinchonism  appears;  even 
though  it  fails  to  check  the  fever  the  patient  is  generally  benefited  by  it. 

Iron  is  a  valuable  remedy  in  this  disease,  but  it  must  not  be  given 
when  there  is  much  fever,  for  it  aggravates  this  symptom. 

Belladonna  is  the  best  remedy  for  checking  the  night-sweats.  Six 
minims  of  the  tincture  of  belladonna,  or  the  one-hundred-and-twentieth 
of  a  grain  of  atropine,  at  bed-time,  is  sufficient  in  many  cases,  but  the 
dose  may  be  increased  to  twice  this  amount,  and  repeated  two  or  three 
times  daily  if  necessary.  For  the  same  purpose,  aromatic  sulphuric  acid, 
v\x.  to  xx.  properly  diluted;  minute  doses  of  aconite;  of  agaricin,  gr.  ^; 
of  zinc  oxide,  gr.  iij.;  of  ergotin,  gr.  ij.;  or  of  black  oxide  of  manganese, 
gr.  ij.;  may  be  given  three  times  daily  with  success  in  some  cases,  but 
any  or  all  may  fail.  I  have  known  obstinate  night-sweats  checked 
occasionally  by  rubbing  into  the  skin  a  powder  of  four  per  cent  of 
salicylic  acid  triturated  with  magnesium  salicylate;  by  placing  a  large 
pan  of  cold  water  under  the  bed  at  night,  by  sleeping  in  light  blankets, 
or  by  drinking  a  preparation  made  by  steeping  for  two  or  three  hours 
two  heaping  tablespoonfuls  of  sago  in  one  and  one-half  pints  of  water, 
reduced  by  evaporation  to  about  one-half  pint. 

Tonic  doses  of  mercury  bichloride  gr.  ^  to  -^,  or  gold  and  sodium 
chloride  gr.  -^  to  yV  will  be  found  beneficial  in  some  cases,  especially 
those  of  a  chronic  catarrhal  or  fibroid  character.  The  same  may  be  said 
of  arsenious  acid,  but  this  must  not  be  given  when  there  is  much  fever. 

When  there  is  a  suspicion  of  syphilitic  origin  of  the  disease,  potas- 
sium iodide  should  be  tried. 


172  PULMONARY  DISEASES. 

As  a  result  of  numerous  experiments  on  Guinea-pigs  and  monkeys, 
E.  L.  Shurly,  of  Detroit,  and  Heneage  Gibbes,  of  Ann  Arbor,  Mich.,  have 
demonstrated  that  animals  may  be  rendered  immune  to  tubercular  virus 
by  hypodermic  injections  of  aqueous  solutions  of  chemically  pure  iodine, 
prepared  by  J.  E.  Clark,  of  Detroit,  or  of  gold  and  sodium  chloride; 
and  they  have  recommended,  for  the  cure  of  consumption,  hypodermic 
injections  of  these  remedies  with  inhalations  of  chlorine  gas.  The  in- 
jections should  be  made  with  an  absolutely  clean  syringe,  which  should 
always  be  washed  with  pure  alcohol  before  and  after  using.  The  treat- 
ment should  be  commenced  with  small  doses,  which  may  be  gradually 
increased  until  some  constitutional  effects  are  observed  or  until  the 
largest  dose  recommended  is  reached.  It  is  usually  best,  excepting  in 
advanced  cases,  to  begin  with  the  iodine  (though  it  is  apt  to  cause  con- 
siderable smarting),  and  it  should  be  continued  ten  to  fourteen  days, 
and  then  may  be  given  alternately  with  the  gold  and  sodium  chloride 
solution,  and  later,  after  four  or  five  Aveeks,  the  gold  solution  may  be 
used  alone  if  everything  is  going  well.  In  some  patients  the  gold  and 
sodium  chloride  answers  best,  but  I  think  most  benefit  will  be  derived 
from  the  iodine.  The  dose  of  iodine  is  from  one-twentieth  to  one-sixth 
of  a  grain,  and  of  the  gold  and  sodium  chloride  from  one-twenty-fourth 
to  one-eighth  of  a  grain. 

When  symptoms  of  iodism  appear  or  there  is  loss  of  appetite,  dis- 
turbance of  the  bowels,  or  complaint  of  unusual  fatigue,  gold  prepara- 
tion may  be  substituted  for  a  day  or  two,  when  the  iodine  may  be  given 
again  in  diminished  doses,  which  may  subsequently  be  gradually  in- 
creased. Sometimes,  while  patients  are  receiving  the  gold  and  sodium 
chloride  in  large  doses,  pains  are  experienced  in  the  bowels,  and  in  some 
instances  there  are  uncomfortable  sensations  in  the  head;  occasionally, 
also,  profuse  sweating  has  been  noticed.  If  any  of  these  symptoms  de- 
velop, the  dose  should  be  at  once  diminished,  or  the  remedy  substituted 
by  the  iodine.  The  most  favorable  place  for  the  injection  is  beneath  the 
loose  skin  in  the  gluteal  region.  As  it  is  difficult  to  get  at  this  point 
on  account  of  the  clothing,  the  injections  are  given  to  women  just 
below  the  inferior  angle  of  the  scapula  or  between  this  and  the  spinal 
column.  Injections  are  advised  daily  for  about  two  weeks,  every  second 
day  for  the  two  following  weeks,  and  subsequently  once  in  three,  four, 
five,  six,  or  seven  days,  gradually  diminishing  the  frequency  according 
to  the  result.  When  these  remedies  are  acting  well,  the  appetite  and 
strength  gradually  improve,  the  weight  increases,  and  the  cough  and  ex- 
pectoration gradually  diminish.  The  chlorine  inhalations  may  be  given 
either  by  means  of  ssme  of  the  common  or  specially  devised  inhalers,  or 
in  a  room  filled  with  chlorine  gas.  The  latter  is  applicable  to  hospitals 
where  small  rooms  can  be  arranged,  or  even  to  small  bedrooms,  where 
it  is  readily  carried  out  in  the  following  manner:  first, a  steam-atomizer 
is  made  to  throw  into  the  atmosphere  of  the  room  a  solution  of  sodium 


TREATMENT  OF  PULMONARY  PHTHISIS.  173 

chloride,  about  fifteen  grains  to  the  ounce;  this  is  continued  until  the 
atmosphere  is  so  permeated  by  the  spray  that  a  person  on  the  opposite 
side  of  the  room  can  taste  the  salt.  One  or  two  teaspoonfuls  of  chlo- 
rinated lime  are  then  placed  upon  a  saucer  and  wet  with  a  mixture  of 
hydrochloric  acid  one  part  and  water  two  parts,  which  causes  the  rapid 
liberation  of  chlorine  gas.  This  is  then  held  directly  under  the  spray  of 
salt  solution,  and  the  gas  is  carried  by  it  into  the  atmosphere  of  the  room, 
where  the  patient  sits  for  ten  or  fifteen  minutes — as  long  as  he  can  well 
tolerate  the  inhalation. 

I  have  employed  this  treatment  in  over  a  hundred  cases  of  phthisis 
during  the  last  few  months,  and  found  it  very  beneficial  in  the  first  stage, 
helpful  in  some  cases  during  the  second  stage  but  of  only  little  value  in 
the  third  stage,  though  occasionally  even  then  some  appear  benefited  by  it. 

Among  other  remedies  in  phthisis,  creasote  has  been  very  highly 
recommended,  in  doses  of  one  to  five  minims,  or  even  as  much  as  half  a 
drachm,  several  times  a  day.  It  has  appeared  to  me  most  beneficial  in 
moderate  or  small  doses  (Form.  7).  Morsen's  creasote  is  seemingly  less 
irritating  than  other  preparations.  Guaiacol,  one  of  the  chief  constitu- 
ents of  creasote,  has  been  quite  extensively  tried  in  the  treatment  of 
pulmonary  tuberculosis.  Although  I  have  had  but  little  experience 
with  it,  general  report,  and  especially  the  apparently  good  results  ob- 
tained from  its  use  in  surgical  tuberculosis  by  Nicholas  Senn  and  W. 
T.  Belfield,  of  Chicago,  induce  me  to  recommend  its  thorough  trial  in 
pulmonary  phthisis.  It  may  be  administered  in  essentially  the  same 
doses  and  manner  as  creasote,  but  I  prefer  the  carbonate  of  guaiacol, 
which  has  but  little  taste  or  odor,  causes  little  irritation,  and  is  appar- 
ently quite  as  efficient  when  given  in  corresponding  doses. 

Oil  of  cloves  given  five  times  a  day,  in  doses  of  two  to  twelve  min- 
ims, or  oil  of  cassia,  in  doses  of  one  to  five  minims,  in  conjunction  with 
other  remedies,  has  been  of  great  benefit  in  some  cases.  The  medicine 
should  be  dropped  in  capsules  just  before  it  is  taken  and  administered 
with  each  meal  and  in  the  middle  of  the  forenoon  and  afternoon,  the 
patient  taking,  when  possible,  a  glass  of  milk  with  each  dose — never 
taking  it  on  an  empty  stomach  lest  it  cause  irritation.  The  dose  should 
be  small  at  first  and  increased,  one-half  to  one  minim  each  day  until 
the  maximum  dose  is  attained  unless  it  disturbs  the  digestive  organs. 

The  therapeutic  value  of  tuberculin  is  still  uncertain,  but  the 
majority  of  those  who  have  tried  it  believe  that  it  is  more  potent  for 
harm  than  for  good. 

Sedative  troches  (Forms.  25,  26,  30,  33,  and  35)  and  sedative  in- 
halations of  benzoin,  opium,  or  chloroform  are  useful  in  allaying  the 
cough  (Forms.  53  to  60).  Stimulant  inhalations  are  frequently  ser- 
viceable in  the  early  stages  of  the  disease.  They  are  most  conveniently 
administered  with  the  Globe  nebulizer  shown  in  Fig.  30.  For  this 
purpose,  iodine,  carbolic  acid,  creasote,  or  oil  of  white  pine  are  most 


174 


PULMONARY  DISEASES. 


frequently  used  (Forms.  62,  68,  69,  and  72  to  74).  Cough  mixtures  are 
necessary,  especially  late  in  the  disease,  but  they  should  be  given  as  spar- 
ingly as  possible.  Sedative  troches  and  inhalations  are  preferable  when 
they  will  answer  the  purpose.  The  neuralgic  pains  which  often  trouble 
phthisical  patients  are  best  prevented  by  regular  and  vigorous  frictions 
of  the  surface  with  a  coarse  towel;  when  severe,  they  are  usually 
promptly  relieved  by  hot  applications  to  the  surface.  These  applica- 
tions should  be  as  hot  as  can  be  borne,  and  should  be  frequently  repeated 
until  pain  subsides. 

Counterirritation  is  useful,  especially  in  cases  of  an  inflammatory 
character,  as  those  growing  out  of  pneumonia,  bronchitis,  or  pleuritis, 
before  tubercles  have  been  deposited. 

I  sometimes  employ  for  this  purpose  an  ointment  composed  of  tartar 


Tig.  30. 


-Globe  Nebulizer.  Lg  Size.     Best  used  with  an  air  pressure  of  ten  or  fifteen  pounds 
only.    It  may  also  be  used  by  the  baud  ball. 


emetic,  croton  oil,  cantharides,  stramonium,  and  camphor  (Form.  10). 
It  is  an  effectual  and  almost  painless  counterirritant.  Burgundy  pitch 
plasters,  croton  oil,  iodine,  or  blisters  may  be  used  for  the  same  purpose. 

The  digestive  functions  must  receive  careful  attention.  Nutritious 
and  easily  digestible  diet  of  varied  character  should  be  ordered. 

Climatic  Treatment. — Many  consumptives  will  be  greatly  benefited 
by  suitable  climatic  influences.  In  the  first  stage  of  phthisis,  I  believe 
that  the  patient's  chances  of  recovery  are  improved  from  fifty  to  seventy- 
five  per  cent  by  residence  in  a  suitable  climate;  in  the  second  stage,  from 
fifteen  to  thirty  per  cent;  in  the  third  stage,  a  small  percentage  will  be 
permanently  benefited;  and  in  a  large  proportion  of  others  life  may  be 
considerably  prolonged. 

There  is  no  climate  to  which  consumptives  may  be  sent  indiscrim- 
inately, but  suitable  places  should  be  selected  for  each  patient.     Some 


TREATMENT  OF  PULMONARY  PHTHISIS.  175 

patients  feel  better  in  cold  weather,  but  the  majority  are  better  in  sum- 
mer. It  will  be  found  that  those  who  feel  best  in  winter  are  likely  to  be 
benefited  by  a  comparatively  cool  climate,  the  others  in  a  warm  climate. 
As  a  rule,  a  warm,  dry  climate  and  high  altitude  are  most  salutary.  It 
is  always  desirable,  when  there  are  no  contra-indications,  that  the  \  atient 
in  the  early  stages  of  the  disease  should  be  sent  to  an  altitude  of  from 
six  to  seven  thousand  feet;  but  this  is  not  suitable  for  those  who  are 
nervous  to  a  marked  degree,  or  who  have  a  high  temperature,  pro- 
nounced cardiac  disease,  emphysema,  or  laryngeal  complications.  Haemop- 
tysis is  not,  as  is  often  supposed,  a  contra-indication  to  a  sojourn  in  a 
high  altitude;  on  the  contrary,  bleeding  is  often  promptly  checked  by 
this  change,  and  those  who  seldom  or  never  have  hemorrhages  in  a  high 
altitude  frequently  experience  them  quickly  upon  a  return  to  a  lower 
level.  In  the  second  stage  of  the  disease,  a  high  altitude  is  often  bene- 
ficial, but  we  cannot  feel  so  certain  of  its  results;  therefore  it  is  best  to 
send  the  patients  to  an  altitude  of  not  more  than  two  or  three  thou- 
sand feet,  and,  if  they  do  well,  subsequently  advise  a  higher  altitude. 

In  the  earlier  stages,  warmth  is  not  so  important,  providing  an  abun- 
dance of  sunshine  and  dry  atmosphere  can  be  obtained,  though  it  is 
usually  best  to  recommend  for  such  patients  a  southern  latitude  in  winter. 

In  this  country  in  summer  the  high  altitude  of  Colorado,  Wyoming, 
Montana,  and  Utah  affords  a  typical  climate  for  these  cases,  whereas  in 
winter  they  generally  do  better  in  New  Mexico,  western  Texas,  or 
Arizona. 

Those  for  whom  an  altitude  of  two  or  three  thousand  feet  is  prefera- 
ble often  do  well  in  summer  in  some  portions  of  Dakota,  Nebraska,  and 
Minnesota;  in  the  Adirondacks,  or  the  mountains  of  Virginia,  North 
Carolina,  or  Tennessee.  In  winter,  more  suitable  climates  are  found  in 
warmer  latitudes;  many  cases  will  do  well  in  eastern  Tennessee  or  west- 
ern North  Carolina  or  in  Georgia  at  from  fifteen  to  eighteen  hundred 
feet  above  the  sea.  The  typical  climate  for  these  cases  in  the  winter 
months  is  found  in  Arizona  or  southern  California,  in  the  latter  among 
the  foot-hills  as  far  as  possible  removed  from  the  ocean.  Southern  New 
Mexico  and  the  western  portion  of  Texas  are  favored  by  a  similar  cli- 
mate. In  many  parts  of  Mexico,  patients  in  the  first  and  second  stages 
of  consumption  do  remarkably  well  during  the  winter  months. 

In  the  Old  World,  the  mountainous  regions  of  southern  Germany, 
of  Switzerland,  Austria,  Spain,  France,  Algiers,  and  Egypt,  according  to 
their  temperature,  offer  advantageous  resorts  for  summer  or  winter. 

In  the  advanced  stage  of  the  disease,  patients,  if  sent  anywhere, 
should  be  recommended  to  a  warm  climate  and  usually  to  a  compara- 
tively low  altitude,  of  not  more  than  one  or  two  thousand  feet  above  the 
sea.  For  these,  a  typical  climate  is  found  in  Arizona  or  southern  Cali- 
fornia, and  many  of  them  do  well  in  Florida,  South  Carolina,  Georgia, 
and  Texas. 


176  PULMONARY  DISEASES. 

In  the  Old  World,  these  patients  also  find  a  suitable  climate  in  southern 
Spain  or  France  and  in  Algiers  or  Egypt,  but  usually  persons  who  have 
passed  to  this  stage  of  the  disease  are  much  better  off  at  home,  where 
they  are  surrounded  by  friends  and  the  comforts  that  cannot  be  ob- 
tained elsewhere.  No  patients  should  be  advised  to  go  from  home  ex- 
cept those  whose  financial  condition  will  enable  them  to  secure  easily 
the  comforts  as  well  as  the  necessaries  of  life,  and  usually  to  surround 
themselves  with  agreeable  companions  and  friends. 


CHAPTER   XI. 

THE   HEART. 

ANATOMY  AND  PHYSIOLOGY. 

A  knowledge  of  the  anatomy  and  physiology  of  the  heart  is  so  essen- 
tial to  a  correct  diagnosis,  that  we  shall  give  them  brief  consideration 
before  proceeding  to  the  means  for  detecting  cardiac  diseases. 

The  heart  is  a  hollow,  muscular  organ  of  conical  form,  which  as  the 
centre  of  circulation  distributes  blood  throughout  the  entire  body. 
Located  near  the  central  portion  of  the  chest,  it  is  held  in  place  above 
by  the  large  blood-vessels  springing  from  its  base,  and  below  by  the  at- 
tachment to  the  diaphragm  of  the  iibro-serous  sac  which  envelops  it.  In 
front  it  is  sheltered  by  the  sternum;  posteriorly  by  the  thick  chest 
walls,  and  spinal  column:  and  laterally  it  is  cushioned  by  the  lungs. 

Its  long  axis  is  oblique  to  the  perpendicular  axis  of  the  chest;  its  base 
is  directed  upward,  outward,  and  backward  toward  the  right  shoulder; 
its  apex  downward  and  forward. 

The  pericardium,  the  fibro-serous  sac  which  envelops  this  organ,  is 
composed  of  an  external,  fibrous  layer  and  an  internal,  serous  layer.  The 
external  layer  incloses  the  arteries  for  about  two  inches  from  the  base  of 
the  heart,  and  is  continuous  with  their  external  covering;  below,  it  is 
attached  to  the  diaphragm.  The  internal,  serous  layer  completely  en- 
velops the  heart,  and  covers  the  blood-vessels  springing  from  its  base 
for  about  two  inches.  It  is  then  reflected  upon  the  inner  surface  of  the 
fibrous  layer,  and  passing  doAvnward  covers  the  upper  surface  of  the 
diaphragm,  beneath  the  heart,  thus  forming  a  closed  sac  similar  to  the 
pleura.  The  two  serous  surfaces  of  the  pericardium,  constantly  in  ap- 
position during  health,  are  moistened  by  serum,  and  glide  upon  each 
other  without  friction  during  the  action  of  the  heart.  The  pericardium 
extends  from  the  level  of  the  second  to  that  of  the  seventh  left  costal 
cartilage.     It  is  farther  from  the  chest  walls  superiorly  than  inf eriorly. 

The  heart,  with  its  pericardium,  is  in  relation :  anteriorly,  with  the 
anterior  borders  of  the  lungs  and  a  small  portion  of  the  thoracic  walls, 
from  which  it  is  separated  by  a  small  amount  of  areolar  tissue;  laterally, 
with  the  lungs  covered  by  the  pleura? ;  posteriorly,  upon  each  side,  with 
the  lungs  and  pleura?.  In  the  middle  line  posteriorly,  it  lies  near  the 
spinal  column,  from  which  it  is  separated  by  cellular  tissue  and  the 
aorta  and  oesophagus. 


178  THE  HEART. 

The  heart  is  about  the  size  of  its  Owner's  fist,  its  weight  ranging  in 
women  from  eight  to  ten  ounces,  in  men  from  ten  to  twelve.  The 
anterior  surface  is  convex;  the  posterior  surface  flattened;  the  right  bor- 
der is  long,  thin,  and  sharp;  the  left  border  is  short,  thick,  and  rounded. 
Eunning  longitudinally  about  the  heart  is  a  well-defined  fissure,  found 
upon  the  anterior  surface  within  half  or  three-quarters  of  an  inch  of  the 
left  border,  and  on  the  posterior  surface  a  similar  distance  from  the 
rio-ht  border.  This  fissure  lodges  the  coronary  arteries,  which  supply 
the  heart  with  blood ;  and  it  indicates  the  position  of  the  septum,  which 
divides  the  right  side  of  the  heart  from  the  left.  Near  the  base  of  the 
heart  is  a  transverse  fissure,  interrupted  in  front  by  the  origin  of  the 
pulmonary  artery.  This  fissure  indicates  the  position  of  the  septum 
between  the  cavities  at  the  base  of  the  heart  and  those  at  the  apex. 

By  these  septa,  the  heart  is  divided  into  four  cavities :  two  above  at  the 
base,  known  as  the  right  and  left  auricles;  two  below  at  the  apex,  known 
as  the  right  and  left  ventricles.  Each  of  these  cavities  is  capable  of  con- 
taining about  two  fluid  ounces.  The  walls  of  the  cavities  upon  the  right 
side  are  thinner  than  those  upon  the  left,  and  the  walls  of  the  auricles 
are  much  thinner  than  those  of  the  ventricles. 

The  right  auricle  receives  the  blood  from  the  venous  system,  through 
the  ascending  and  descending  venae  cava?,  and  transmits  it  through  the 
auriculo-ventricular  opening,  into  the  right  ventricle,  which,  contracting, 
forces  the  blood  onward  through  the  pulmonary  artery  into  the  lungs. 
The  left  auricle,  receiving  the  blood  from  the  lungs  through  the  pul- 
monary veins,  transmits  it  to  the  left  ventricle,  whence  it  is  distributed, 
by  the  aorta  and  its  branches,  throughout  the  body. 

The  internal  surface  of  the  heart  is  lined  by  a  glistening  membrane, 
known  as  the  endocardium,  folds  of  which  at  the  various  orifices  con- 
stitute the  valves.  At  the  orifice  between  the  right  auricle  and  the  right 
ventricle,  we  find  three  of  these  folds,  which  are  named  the  tricuspid 
valves.  At  the  orifice  of  the  pulmonary  artery  are  three  similar  folds, 
known  as  the  pulmonary  semi-lunar  valves.  At  the  aortic  orifice  are  a 
similar  number,  called  the  aortic  semi-lunar  valves.  At  the  orifice  between 
the  left  auricle  and  ventricle  are  two  folds,  known  as  the  mitral  valves. 

The  greater  portion  of  the  heart  lies  beneath  the  lower  part  of  the 
sternum,  but  the  right  auricle,  and  a  small  part  of  the  right  ventricle, 
extend  from  one-half  to  three-fourths  of  an  inch  to  the  right  of  the 
sternum;  the  ventricles  extend  about  two  inches  to  the  left  (Fig.  1). 

The  auricles  are  on  a  line  with  the  third  ribs,  the  right  auricle  ex- 
tending considerably  beyond  the  sternum  into  the  third  interspace  upon 
the  right  side,  the  left  being  located  beneath  the  third  left  costal  carti- 
lage and  intercostal  space  upon  the  left.  The  left  ventricle  lies  mainly 
behind  the  right;  that  part  of  it  which  is  superficial  is  found  entirely 
to  the  left  of  the  sternum.  Most  of  the  right  ventricle  lies  behind  the 
lower  part  of  the  sternum;  but  a  small  part  of  it,  at  the  base,  extends  to 


ANATOMY  AND  PHYSIOLOGY  OF  THE  HEART.  179 

the  right  of  the  sternum,  and  its  apex  is  found  to  the  left  of  this  bone 
in  the  triangular  space  between  the  sternum  and  the  margin  of  the  left 
lung.  The  base  of  the  heart  extends  to  the  upper  margin  of  the  third 
rib,  corresponding  behind  to  the  sixth  and  seventh  dorsal  vertebras;  its 
apex  lies  at  the  fifth  costal  interspace  from  an  inch  and  a  half  to  two 
inches  below  the  nipple,  about  half  an  inch  to  the  right  of  the  mammil- 
lary  line,  and  two  or  two  and  a  half  inches  to  the  left  of  the  sternum. 
The  position  of  the  apex  changes  slightly  with  the  respiratory  move- 
ments, the  position  of  the  patient,  or  with  the  distention  of  the  stomach. 

It  is  said  that  the  apex  may  move  as  much  as  an  inch  and  a  half  from  left  to 
right,  or  vice  versa,  when  the  patient  lies  on  the  right  or  the  left  side  ;  a  few 
cases  have  been  reported  in  which  prolonged  decubitus  on  one  side  seems  to 
have  caused  permanent  dislocation  of  the  heart. 

From  the  base  to  the  apex  of  the  heart,  in  a  vertical  line,  the  dis- 
tance is  about  five  inches.  Measuring  from  the  mesosternal  line  to  the 
left  over  the  third  rib,  the  heart  extends  from  two  and  one-half  to  three 
inches,  over  the  fourth  rib  three  and  one-half  to  four  inches,  and  in 
the  fifth  interspace  from  three  to  three  and  one-half  inches. 

Position  of  the  Valves. — The  relation  of  the  valves  to  the  surface  of 
the  chest  may  be  ascertained  by  passing  needles  through  the  chest  walls 
of  the  cadaver  before  the  thorax  is  opened.  In  this  manner  it  has  been 
ascertained  that  the  pulmonary  valves  lie  beneath  the  junction  of  the 
third  costal  cartilage  of  the  left  side  with  the  sternum.  The  mitral 
valves  lie  close  to  the  left  border  of  the  sternum  in  the  third  intercostal 
space.  The  tricuspid  valves  lie  in  front  of  the  mitral,  near  the  middle 
of  the  sternum,  on  a  line  with  the  fourth  ribs.  The  aortic  valves  lie 
beneath  the  sternum,  just  below  the  level  of  the  third  ribs,  and  a  little 
to  the  left  of  the  median  line  (Fig.  1).  As  indicated  in  treating  of  the 
chest  regions,  a  very  small  circle,  with  its  centre  at  the  left  edge  of  the 
sternum  in  the  third  intercostal  space,  will  include  the  greater  part  of 
all  of  these  valves. 

The  discrepancy  noticeable  in  the  descriptions,  by  different  authors,  of  the 
position  of  the  valves  is  probably  due,  in  the  main,  to  their  being  located  after 
the  thorax  has  been  opened,  when  the  collapse  of  the  lungs  has  more  or  less 
displaced  the  heart. 

The  aorta  springs  from  the  base  of  the  left  ventricle,  and  passes 
upward,  forward,  and  to  the  right,  to  the  second  intercostal  space,  where 
it  is  more  superficial  than  in  any  other  part  of  its  course.  In  this  situ- 
ation, it  is  within  the  pericardial  sac;  thence  it  passes  backward,  upward, 
and  to  the  left,  and  finally  passes  downward,  bending  completely  upon 
itself,  so  as  to  rest  along  the  left  side  of  the  fifth  and  sixth  dorsal  ver- 
tebrae. The  highest  portion  of  the  arch  is  on  a  line  with  the  first  costo- 
sternal  articulation. 


130  THE  HEART. 

The  pulmonary  artery  rises  from  the  base  of  the  right  ventricle,  be- 
neath the  third  costal  cartilage  at  its  junction  with  the  sternum,  and 
passes  upward  and  outward,  about  two  inches,  to  the  second  costal  carti- 
lage, where  it  bifurcates,  one  of  the  branches  going  to  each  lung.  It 
will  be  seen  that  the  aorta  may  be  found  close  to  the  margin  of  the  ster- 
num in  the  second  intercostal  space  upon  the  right  side,  and  the  pul- 
monary artery  in  a  similar  position  on  the  left. 

PHYSIOLOGICAL  ACTION   OF  THE   HEART. 

In  health,  the  heart  acts  as  a  perfect  automatic  engine,  the  strokes 
of  which  follow  each  other  in  regular  succession,  continuing  from  total 
life  until  the  moment  of  death. 

The  pulsations  of  the  heart  consist  of,  first,  contraction,  then  dilata- 
tion of  its  walls;  this  is  followed  by  a  short  period  of  rest.  These  pul- 
sations occur  in  the  adult  from  seventy  to  eighty  times  per  minute. 
During  their  occurrence  the  blood  is  flowing  from  the  auricles  into  the 
ventricles,  and  from  these  on  into  the  arteries,  and  the  valves  guarding 
the  orifices  of  the  heart  are  opening  and  closing  synchronously  with  its 
contraction  and  dilatation  (Figs.  34  and  35).  The  contraction  of  the 
heart  is  known  as  its  systole  ;  the  dilatation,  as  its  diastole. 

The  cardiac  pulsation  begins  with  auricular  systole,  which  occupies 
about  one-eighth  of  the  period  of  a  complete  pulsation.  While  this  is 
taking  place,  the  blood  is  flowing  through  the  auriculo-ventricular  open- 
ings into  the  ventricles,  and  the  mitral  and  tricuspid  valves  float  out 
upon  the  current,  causing  no  obstruction  (Figs.  34  and  35). 

The  systole  of  the  auricles  is  followed  immediately  by  their  diastole, 
a  passive  movement  which  continues  from  the  end  of  the  systole 
to  the  beginning  of  the  next  pulsation.  This  occupies  seven-eighths 
of  the  time  of  a  complete  cardiac  pulsation.  During  the  diastole  of 
the  auricles,  the  blood  is  again  filling  them  from  the  vena?  cava?  and 
pulmonary  veins.  The  contraction  of  the  cardiac  muscular  fibres  passes 
with  a  wavy  motion  from  the  auricles  to  the  ventricles,  so  that  the  ven- 
tricular systole  immediately  follows  that  of  the  auricles. 

During  the  systole  of  the  ventricles,  the  vertical  diameter  of  the  heart 
is  shortened;  the  apex  approximates  more  nearly  to  the  base;  at  the 
same  time  it  describes  a  spiral  motion  from  left  to  right  and  from  be- 
hind forward,  striking  against  the  chest  wall  between  the  fifth  and  sixth 
ribs,  where  its  impulse  may  usually  be  seen  and  felt. 

"With  this  contraction  there  is  sudden  closure  of  the  mitral  and  tri- 
cuspid valves.  The  semi-lunar  valves  being  thrown  open  by  the  current, 
the  blood  is  carried  onward  into  the  aorta  and  the  pulmonary  artery 
(Fig.  35).  The  time  occupied  by  the  systole  of  the  ventricles  is  about 
three-eighths  of  a  complete  pulsation.  With  the  closure  of  the  mitral 
and  tricuspid  valves,  we  may  hear  the  first  sound  of  the  heart. 


PHYSIOLOGICAL  ACTION  OF  THE  HEART. 


181 


The  ventricular  diastole  follows  immediately  after  their  systole. 
The  elastic  tissue  of  the  arteries  contracts,  forcing  a  portion  of  the  blood 
backward  toward  the  heart,  which  it  is  prevented  from  entering  by  the 
abrupt  closure  of  the  semi-lunar  valves  that  guard  the  aortic  and  pul- 
monary orifices. 

With  diastole  of  the  ventricles  the  heart  assumes  its  former  shape  and 
position,  the  auriculo-ventricular  valves  open,  and  blood  flows  passively 
into  the  ventricles.  This  occupies  about  one-fourth  of  the  period  of  a 
complete  cardiac  pulsation. 

Closure  of  the  semi-lunar  valves,  which  is  caused  by  the  contraction 
of  the  arteries,  produces  the  second  sound  of  the  heart. 

The  diastole  of  the  ventricles  is  followed'  by  a  period  of  rest,  which 
occupies  about  one-fourth  of  the  time  for  a  complete  pulsation. 

During  this  period,  the  blood  continues  to  flow  from  the  auricles 
into  the  ventricles,  so  that,  at  the  instant  just  preceding  another  pulsa- 


Tibial'Puiu  Radial  Pulse 

Fig.  31. — Physiological  action  op  the  heart  (altered  slightly  from  Gairdner). 

In  the  diagram,  the  inner  circle  represents  the  physiological  action  of  the  heart,  apart  from 
any  manifest  signs. 

The  outer  circle  represents  the  external  manifestations  of  the  heart's  action:  the  ring  between 
the  circles  illustrates  the  sounds  and  periods  of  silence;  out  side  of  the  outer  circle  represents  the 
impulse  of  the  apex  against  the  chest  wall.  Lines  radiating  from  the  centre  represent  the  pulse 
in  the  neck,  wrist,  and  ankle. 


tion,  all  of  the  cavities  of  the  heart  are  full,  but  not  distended.  With 
the  contraction  of  the  auricles,  the  ventricles  are  distended  by  an  addi- 
tional amount  of  blood,  but  probably  the  auricles  are  not  completely 
emptied.  The  distention  of  the  ventricles,  caused  by  the  systole  of  the 
auricles,  excites  their  contraction,  and  the  blood  is  forced  onward  into 
the  arteries.  If  the  cycle  of  time  taken  up  by  a  cardiac  pulsation  were 
divided  into  five  equal  parts,  about  one-fifth  would  be  occupied  by  the 
systole  of  the  auricles,  two-fifths  by  the  systole  of  the  ventricles,  and 
two-fifths  by  the  diastole  of  the  ventricles  and  the  period  of  repose. 
The  physiological  action  of  the  heart  is  graphically  represented  by  a 
modification  of  Gairdner's  diagram  (Fig.  31). 


182  THE  HEART. 

As  seen  by  the  diagram,  the  systole  of  the  auricles  gives  rise  to  no 
external  manifestations,  but  with  the  beginning  of  the  ventricular  sys- 
tole we  appreciate  the  first  sound  of  the  heart  and,  at  the  same  time, 
we  may  feel  the  beat  of  the  apex  against  the  chest  wall,  and  the  carotid 
pulse. 

The  long,  first  sound,  as  indicated  in  the  diagram,  is  followed  by  a 
short  period  of  silence,  known  as  the  first  silence,  during  which  the 
radial  pulse  may  usually  be  felt. 

Immediately  following  the  first  silence  the  ventricular  diastole 
begins,  and  with  it  occurs  the  second  sound  of  the  heart,  which,  as  in- 
dicated in  the  diagram,  is  shorter  than  the  first,  and  is  followed  by  the 
second  or  long  silence,  extending  through  the  period  of  rest  and  the 
time  occupied  by  the  auricular  systole. 

In  some  cases  only  one  sound  of  the  heart  can  be  heard,  either  at  the 
apex  or  at  the  base.  In  such  instances,  in  order  to  determine  which  is 
the  first  and  which  the  second,  it  is  absolutely  necessary  to  associate  the 
sound  with  the  arterial  pulsation.  This  can  only  be  done,  in  the  major- 
ity of  cases,  by  feeling  for  the  carotid  pulse,  which  occurs  with  the  first 
sound  of  the  heart.  If  the  heart  were  beating  slowly,  it  might  be  easy 
to  recognize  the  position  of  the  radial  pulse  between  the  first  and  second 
sounds;  but  as  the  length  of  the  first  silence,  during  which  this  may  be 
felt,  does  not  usually  exceed  the  tenth  of  a  second,  it  is  difficult  to  be 
certain  whether  it  accompanies  the  latter  part  of  the  first  or  the  first 
part  of  the  second  sound.  Knowledge  of  the  instant  when  the  carotid 
pulsation  or  the  apex  beat  takes  place  is  indispensable  in  ascertaining 
whether  an  abnormal  sound  precedes  or  accompanies  the  systole  of  the 
ventricles. 

The  regular  contraction,  dilatation,  and  rest  of  the  heart  consti- 
tute what  is  known  as  its  rhythm.  In  health,  each  pulsation  is 
similar  in  every  respect  to  those  which  precede  and  follow  it.  In 
disease  of  the  heart,  alterations  in  the  rhythm  are  among  the  most 
constant  signs;  and  in  all  the  affections  giving  rise  to  abnormal  sounds 
produced  at  the  valvular  orifices,  the  signs  occur  with  either  contraction 
or  dilatation  of  the  organ.  It  therefore  becomes  necessary  in  the  physical 
diagnosis  of  cardiac  disease  to  ascertain  the  rhythm  of  the  heart.  When 
the  pulsations  are  of  normal  frequency  this  is  an  easy  matter,  if  we 
recollect  that  the  first  sound  is  dull,  heavy,  and  prolonged,  while  the 
second  sound  is  comparatively  short  and  clacking,  and  that  the  period 
of  rest,  or  long  silence,  follows  the  second  and  precedes  the  first,  and 
also  the  first  sound  is  coincident  with  the  carotid  pulse  and  the  impulse 
of  the  apex  beat.  If  the  heart  is  beating  more  than  a  hundred  times 
per  minute,  it  is  always  difficult,  and  frequently  impossible,  by  ausculta- 
tion alone,  to  distinguish  between  the  two  sounds. 

If  we  divide  the  entire  period  of  the  cardiac  pulsations  into  two  parts,  one  of 
motion  and  the  other  of  rest,  it  at  once  becomes  evident  that  the  more  rapid  the 


PHYSICAL  EXAMINATION  OF  THE  HEART. 


183 


pulsations  the  shorter  must  be  the  period  of  repose,  and  consequently  the  shorter 
will  be  the  silence  between  the  two  sounds  of  the  heart.  This  is  well  illustrated 
by  a  series  of  circles  of  increasing  size  (Fig.  32). 

In  the  first  or  smallest  circle,  which  indicates  the  most  rapid  pulsation  of  the 
heart,  the  intervals  between  the  first   and   second,  and  the  second  and  first, 

1 


Fig.  32.— Rhythm  of  the  Heart  (Loomis). 

sounds  are  equal  ;  whereas  in  the  largest  circle,  in  which  the  interval  between 
the  first  and  second  sounds  is  represented  by  the  same  distance  upon  the  circum- 
ference as  in  the  small  circle,  the  time  between  the  second  and  the  first  sound  is 
greatly  increased,  as  indicated  by  the  greater  distance  on  the  circumference. 
In  the  small  circle  the  time  between  the  first  and  the  second  sound  is  equal  to  that 
between  the  second  and  the  first,  while  in  the  large  circle  the  time  between  the 
first  and  the  second  sound,  which  corresponds  to  the  period  of  motion,  is  only 
about  one-fourth  as  great  as  that  which  includes  the  period  of  rest  between  the 
second  and  the  first. 

PHYSICAL  EXAMINATION  OF  THE  HEART. 

The  methods  employed  in  examination  of  the  heart  are  those  already 
described,  except  succussion. 

Upon  inspection  of  a  patient  suffering  from  cardiac  advanced  dis- 
ease, we  often  observe  a  peculiar  sodden  expression,  with  puffmess  of 
the  lower  eyelids.  In  many  instances  there  is  marked  pulsation  of  the 
veins  and  arteries  at  the  base  of  the  neck.  Slight  pulsation  of  the 
jugular  vein  is  not  a  sign  of  cardiac  disease,  for  it  maybe  caused  normally 
by  the  auricular  contraction.  Distinct  systolic  jugular  pulsation  in  this 
position  is  always  associated  with  more  or  less  dilatation  of  the  right 
side. of  the  heart,  which  may  result  from  protracted  emphysema,  mitral 
disease,  or  obstruction  of  the  pulmonary  artery  by  embolism  or  throm- 
bosis. When  very  marked,  especially  on  the  right  side,  it  is  always  as- 
sociated with  dilatation  of  the  right  ventricle  and  regurgitation  of  blood 
through  the  tricuspid  valves,  by  which  the  impulse  is  transmitted  di- 
rectly to  the  jugular  veins,  as  there  are  no  valves  guarding  the  opening 
of  the  descending  vena  cava  into  the  right  auricle.  Pulsation  in  the 
veins  is  always  most  distinct  when  the  patient  is  lying  down,  and  may 
be  rendered  still  more  noticeable  by  pressing  the  blood  upward  in  the 
vein  with  the  finger,  and  allowing  the  vessel  to  refill  from  below. 

Visible  pulsation  in  the  superficial  arteries  is  not  uncommon  in  con- 
ditions of  health;  but  when  this  is  excessive  and  symmetrical  in  the 
carotid,  subclavian,  and  brachial  arteries,  it  is  always  due  to  hypertrophy 
and  dilatation  of  the  left  ventricle,  with  regurgitation  through  the  aortic 
valves.     Marked  pulsation  confined  to  one  subclavian  or  carotid  artery 


184  THE  HEART. 

usually  indicates  dilatation  of  the  vessel,  and  the  commencement  of  an 
aneurism. 

By  inspecting  the  chest,  Ave  obtain  information  regarding  the  form 
of  the  cardiac  region  and  the  position  and  character  of  the  apex  beat. 

Enlargement  or  bulging  of  the  precordial  region  may  be  normal,  but 
it  is  frequently  due  to  enlargement  of  the  heart  or  effusion  into  the 
pericardial  sac.  In  this  latter  instance,  the  intercostal  spaces  are  more 
prominent  than  in  the  former. 

The  unusually  distinct  pulsations  often  seen  in  children  and  emaciated  per- 
sons have  been  mistaken  for  bulging  ;  but  such  errors  may  be  avoided  by  careful 
inspection  and  palpation. 

Rachitis  may  cause  bulging  of  the  precordial  region,  but  in  such  in- 
stances a  corresponding  depression  is  usually  found  on  the  posterior 
aspect  of  the  chest,  immediately  to  the  left  of  the  spine,  and  the  spine 
is  generally  curved. 

Prominence  anteriorly  caused  by  aneurism  of  the  aorta  is  found  only 
above  the  fourth  rib. 

Depression  in  the  precordial  region,  of  a  permanent  character,  usu- 
ally indicates  previous  pericarditis  with  adhesion  of  the  two  surfaces  of 
the  pericardium  to  each  other,  and  of  the  pericardium  to  the  costal 
pleura. 

Care  must  be  taken  not  to  confound  with  this  condition  those  rhythmical  de- 
pressions which  may  occur  independent  of  adhesions,  as  the  result  of  atmo- 
spheric pressure.  These  take  place  when  the  heart  is  enlarged  and  the  left  lung 
contracted,  provided  the  person  has  thin  and  elastic  chest  walls. 

Inspection  reveals  any  alteration  in  the  position,  character,  and  force 
of  the  apex  beat.  The  apex  is  crowded  upward  and  outward  by  hyper- 
trophy of  the  left  lobe  of  the  liver  or  by  abdominal  tumors.  It  may  be 
carried  directly  upward  to  a  point  above  the  fifth  rib  by  pericardial 
effusions;  it  is  raised  by  contraction  of  the  left  lung,  as  in  fibroid 
phthisis.  It  is  crowded  downward  and  to  the  right,  when  the  left  lung 
is  enlarged  by  emphysema,  or  it  may  be  drawn  in  the  same  direction  by 
contraction  of  the  right  lung-.  It  is  crowded  to  the  right  by  collections 
of  fluid  or  of  air  in  the  left  pleural  sac,  or  by  large  tumors  occupying 
that  side  of  the  chest;  to  the  left,  by  corresponding  conditions  upon  the 
right  side.  It  is  forced  downward  by  aneurisms  or  by  other  medias- 
tinal tumors  and  is  drawn  downward  and  inward  by  hypertrophy  of  the 
right  ventricle.  It  is  carried  downward  and  to  the  left  by  hypertrophy 
of  both  ventricles,  but  in  uncomplicated  hypertrophy  the  apex  seldom 
extends  more  than  an  inch  to  the  left  of  its  normal  position.  It  is  also 
carried  downward,  and  often  far  to  the  left,  by  enlargement  of  the  heart, 
as  the  result  of  dilatation  or  of  dilatation  and  hypertrophy  combined. 
The  significance  of  alterations  in  the  position  of  the  apex  beat  is  shown 
at  a  glance  in  the  following  table: 


PHYSICAL  EXAMINATION  OF  THE  HEART.  185 

Displacements  of  the  Apex.  Significance. 

Apex  crowded  to  the  right  or  left.  Fluid,  air,  or  tumors  in  opposite  side 

of  chest,  or  contraction  of  the  corre- 
sponding lung. 
Apex  raised.  Pericardial  effusions.      Contraction 

of  left  lung. 
Apex  more  or  less  upward  and  out-  Hypertrophy  of  the  left  lobe  of  the 

ward  (to  the  left).  liver.     Abdominal    tumors    and    peri- 

cardial effusion. 
Apex  depressed.  Aneurism  or  other  mediastinal  tu- 

mors. 
Apex  more  or  less  downward  and  to  Pulmonary   emphysema.      Contrac- 

tile right.  tion  of  the  right  lung  or  hypertrophy 

of  the  right  ventricle. 
Apex  more  or  less  downward  and  to  Hypertrophy  of    the    left    or    both 

the  left.  ventricles.     Dilatation    of  the  heart. 

Hypertrophy  with  dilatation. 

The  area  over  which  the  cardiac  impulse  can  be  seen  is  increased  in 
all  those  diseases  which  cause  enlargement  of  the  heart. 

Feeble  pulsations  above  the  fourth  rib  are  usually  due  to  auricular 
contraction,  but  they  may  be  caused  by  an  aneurism  of  the  aorta.  These 
two  conditions  can  be  distinguished  from  each  other  by  noting  the  time 
of  their  occurrence.  Pulsation  of  the  auricles  always  precedes  the  apex 
beat,  while  that  of  an  aneurism  must  necessarily  follow  or  accompany  it. 
If  the  heart  is  acting  slowly,  this  distinction  can  be  made  easily  by  ordi- 
nary inspection,  but  this  is  not  the  case  if  it  is  beating  rapidly.  Under 
such  circumstances  the  differentiation  is  facilitated  by  attaching,  by 
means  of  wax,  two  bristles,  each  carrying  a  paper  flag,  to  the  two  pulsat- 
ing points,  one  over  the  apex  and  the  other  above  the  fourth  rib.  By 
watching  their  movements,  it  will  be  easy  to  determine  which  is  first  and 
which  second. 

When  there  is  dilatation  of  the  ventricles,  or  when  agglutination  of 
the  two  surfaces  of  the  pericardium  has  taken  place,  the  character  of 
the  impulse  is  wavy  or  undulating;  it  may  sometimes  be  seen  over  the 
entire  precordial  region. 

Alterations  in  the  force  of  the  impulse  may  be  recognized  ordinarily 
upon  inspection,  but  can  be  better  appreciated  by  palpation. 

Before  examining  the  heart  by  palpation,  it  is  always  desirable  to 
ascertain  the  condition  of  the  pulse,  the  signs  furnished  by  which  are 
sometimes  sufficient  to  establish  the  diagnosis. 

If  the  radial  pulse  is  of  unequal  force  upon  the  two  sides,  it  is  prob- 
ably caused  by  an  aneurism,  though  it  may  depend  upon  an  abnormal 
distribution  of  the  arteries.  In  the  latter  case  pulsations  in  the  brachial 
arteries  are  alike  on  the  two  sides;  whereas,  in  case  of  aortic  aneurism, 
they  vary  in  force. 


186  THE  HEART. 

If  the  pulse  is  small  and  weak  when  the  arm  is  hanging  in  the  natu- 
ral position,  and  if  it  disappears  upon  raising  the  arm,  general  anaemia 
is  present,  and  it  may  be  the  only  cause  for  this  sign.  When  the  arm  is 
in  the  natural  position,  if  the  pulse  is  small  and  weak,  and  if  it  main- 
tains the  same  characteristics  when  the  arm  is  elevated,  there  is  likely 
to  be  disease  at  the  mitral  valves;  if  the  pulse  is  also  very  irregular,  it  is 
probably  caused  by  mitral  stenosis. 

If  the  pulse  is  small  and  irregular,  but  distinct,  and  upon  elevation 
of  the  arm  becomes  still  more  distinct,  two  lesions  are  present,  one  at 
the  mitral  valves,  and  the  other  at  the  aortic. 

If  the  pulse  is  full  and  distinct  with  the  arm  in  its  natural  position, 
and  becomes  much  more  distinct  and  assumes  the  characteristics  known 
as  hammer  pulse  when  the  arm  is  elevated,  there  is  probably  regurgi- 
tation through  the  aortic  valves,  with  more  or  less  hypertrophy  and 
dilatation  of  the  left  ventricle. 

Upon  examining  the  chest  by  palpation,  we  obtain  evidence  concern- 
ing the  force,  frequency,  and  regularity  of  the  heart's  action,  and  we 
may  detect  abnormal  pulsations  or  thrills. 

By  pressing  firmly  upon  the  sternum  with  one  hand,  while  the  other 
is  pressed  upon  the  back,  we  are  sometimes  able  to  detect  pulsations 
in  a  slightly  dilated  aorta  which  could  not  be  felt  in  the  ordinary 
manner. 

The  position  of  the  impulse  is  to  be  noted.  Forcible  pulsation  above 
the  fourth  rib  may  be  due  to  an  aneurism;  but  if  observed  to  the  left  of 
the  sternum,  it  is  ordinarily  caused  by  hypertrophy  and  dilatation  of  the 
left  auricle.  The  two  conditions  may  be  differentiated  by  observing 
whether  the  pulsation  precedes  or  follows  the  apex  beat. 

When  the  left  lung  is  retracted  from  the  base  of  the  heart,  pulsation 
of  the  pulmonary  artery  may  be  frequently  seen  in  the  second  inter- 
costal space.  It  can  be  distinguished  from  pulsations  of  the  auricle  by 
the  time  of  its  occurrence. 

Abnormal  pulsations  along  the  course  of  the  aorta  are  nearly  always 
aneurismal;  but  in  very  rare  instances  they  are  caused  by  displacement 
of  the  artery,  as  in  rachitis.  If  the  pulsations  are  feeble,  they  can  be 
most  distinctly  felt  during  expiration. 

Pulsation  beneath  the  lower  portion  of  the  sternum,  and  in  the  epi- 
gastric region,  with  disappearance  of  the  apex  beat,  is  a  sign  of  enlarge- 
ment of  the  right  ventricle. 

The  force  of  the  heart  may  be  increased  or  diminished. 

The  force  is  increased  in  simple  hypertrophy,  and  in  hypertrophy 
with  dilatation,  whenever  the  former  more  than  compensates  for  the 
latter.  It  is  slightly  increased  in  the  early  stages  of  endocarditis,  and 
of  pericarditis ;  and  it  is  increased  by  simple  irritability  of  the  heart,  as 
in  hysterical  jmlpitation. 


PHYSICAL   EXAMINATION  OF  THE  HEART  187 

Occasionally  a  double  shock  is  felt  in  case  of  extensive  hypertrophy 
and  dilatation,  due  to  the  rebound  of  the  heart  after  its  systole. 

The  force  is  diminished  when  the  chest  walls  are  very  thick,  in  con- 
sequence of  a  large  amount  of  adipose  tissue;  when  the  heart  is  abnor- 
mally separated  from  the  chest  walls,  as  in  pulmonary  emphysema;  and 
when  there  is  effusion  into  the  pericardial  sac.  It  is  also  diminished 
when  the  heart  is  enfeebled  by  atrophy,  fatty  degeneration  and  soften- 
ing, or  general  muscular  debility  resulting  from  protracted  or  low  forms 
of  fever  or  other  disease. 

The  position  of  the  apex  beat  can  often  be  detected  by  palpation 
when  it  is  not  perceptible  upon  inspection.  It  is  altered  by  the  diseases 
mentioned  in  speaking  of  inspection. 

The  frequency  of  the  heart's  action  is  increased  in  such  a  great  vari- 
ety of  diseases  that  it  is  not  a  sign  of  much  importance  in  the  diagnosis 
of  cardiac  affections. 

Irregularity  of  the  heart's  action  is  often  a  sign  of  disease  in  this 
organ. 

When  the  pericardial  surfaces  are  roughened  by  exudation,  friction 
fremitus  may  be  obtained.  This  is  usually  most  distinct  in  the  fourth 
intercostal  space,  near  the  left  margin  of  the  sternum. 

Regurgitation  through  the  valvular  orifices  gives  rise  to  a  peculiar 
vibration  known  as  the  purring  tremor  or  thrill,  which  may  be  felt  by 
the  fingers.  This  is  sometimes  detected  by  simply  touching  the  sur- 
face, but  in  other  instances  firm  pressure  must  be  made. 

Exceptional. — The  same  sensation  is  occasionally  communicated  from  the 
larger  arteries. 

Feeble  epigastric  pulsation  is  frequently  found  in  perfectly  healthy 
individuals;  but  pulsation  in  this  locality,  associated  with  absence  of 
the  apex  beat  from  its  normal  position,  is  generally  the  result  of  dilatation 
of  the  right  ventricle,  with  or  without  hypertrophy.  This  is  a  common 
sign  of  dilatation  of  the  right  side  of  the  heart  caused  by  pulmonary 
emphysema.  Epigastric  pulsation  may  be  due  to  the  impulse  of  the 
abdominal  aorta,  especially  in  emaciated  people  who  have  formerly  been 
of  full  habit.  It  occurs  also  when  a  tumor  rests  upon  the  aorta  in  such 
a  manner  as  to  be  lifted  with  each  pulsation;  and  it  is  one  of  the  sicns 
of  aneurism  of  this  artery. 

Exceptional. — Sometimes  epigastric  pulsation  is  due  to  the  action  of  the 
heart  upon  the  left  lobe  of  the  liver. 

Hepatic  pulsation  in  a  few  rare  instances  is  caused  by  venous  regurgitation 
from  a  dilated  right  ventricle,  through  the  tricuspid  valves  and  the  right  auricle, 
into  the  ascending  vena  cava.  It  sometimes  extends  over  the  entire  hypochon- 
driac region  of  the  right  side,  but  in  other  instances  it  is  limited  to  a  portion  of 
the  liver.  Similar  pulsations  are  observed  in  very  rare  cases,  as  the  result  of  an 
aneurism,  the  pulsations  of  which  are  transmitted  through  the  liver. 

Sometimes  a  peculiar  pulsation  is  communicated  to  the  epigastric  region  by 


188  THE  HEART. 

the  systole  of  the  heart,  the  apex  of  which  draws  the  diaphragm  upward  in  con- 
traction instead  of  crowding  it  downward,  in  consequence  of  agglutination  of  the 
two  surfaces  of  the  pericardium.  This  pulsation  is  the  reverse  of  that  ordinarily 
observed,  the  expansion  taking  place  with  the  dilatation  instead  of  with  the  con- 
traction of  the  heart. 

By  percussion,  we  learn  the  size  of  the  heart,  or  detect  collections  of 
fluid  or  air  in  the  pericardium.  It  is  generally  considered  very  difficult 
to  map  out  this  organ  by  percussion,  but  by  attention  to  the  following 
rules  we  find  it  comparatively  easy.  The  patient  should  be  in  the  re- 
cumbent posture  when  the  examination  is  made,  and  the  force  of  the 
blow  should  be  proportionate  to  the  depth  of  the  part  to  be  examined. 
To  learn  the  extent  of  the  cardiac  area  which  is  not  covered  by  lung,  we 
must  percuss  lightly;  to  learn  the  deeper  outlines  of  the  organ,  a  harder 
stroke  must  be  made. 

For  clinical  purposes,  it  is  not  necessary  to  find  the  exact  limits  of 
the  heart  in  every  direction,  for  our  results  will  be  ecmally  good  if  we 
ascertain  simply  the  upper,  lower,  and  lateral  lines  of  dulness,  over  its 
greater  diameters. 

To  find  the  base  of  the  heart,  percussion  should  be  performed  on  a 
line  parallel  to  the  sternum  and  about  an  inch  to  the  left,  so  as  to  avoid 
the  dulness  occasioned  by  the  aorta  and  the  pulmonary  artery,  which  in 
no  way  differs  from  that  of  the  heart  itself.  On  this  line  percussion 
should  be  made  from  above  downward,  until  we  reach  the  upper  limit  of 
cardiac  dulness,  ordinarily  found  at  the  third  rib. 

To  locate  the  lateral  boundaries,  percussion  should  be  made  in  the 
fourth  intercostal  spaces.  Beginning  in  the  right  mammary  region, 
where  there  is  perfect  resonance,  the  examination  should  be  carried 
gradually  toward  the  sternum,  until  the  cardiac  dulness  is  reached; 
which  will  usually  be  about  half  an  inch  to  the  right  of  this  bone. 

Upon  the  left  side,  the  examination  should  be  commenced  left  of  the 
line  of  the  nipple,  and  carried  gradually  toward  the  sternum,  until  car- 
diac dulness  is  obtained,  usually  about  half  an  inch  to  the  right  of  the 
mammillary  line. 

It  is  a  difficult  matter,  by  simple  percussion,  to  find  the  lower  border 
of  the  heart,  since  it  lies  immediately  above  the  left  lobe  of  the  liver, 
and  a  distinction  between  the  dull  or  flat  sounds  produced  by  these 
two  organs  is  hardly  practicable.  If  we  find  the  apex  of  the  heart  either 
by  palpation  or  by  auscultation,  and  then  the  upper  surface  of  the  liver, 
in  the  right  mammary  region,  by  forcible  percussion,  and  draw  a  straight 
line  between  these  two  points,  it  will  correspond  almost  exactly  with  the 
inferior  border  of  the  heart. 

Cardiac  Dulness. — In  a  small  triangular  space  at  the  inner  part  of 
the  left  mammary  region,  and  at  the  lower  part  of  the  sternum,  the 
heart  lies  close  to  the  chest  wall,  not  being  covered  by  the  anterior  border 
of  the  lung  (Fig.  1).     This  area,  which  is  about  two  and  one-half  inches 


PHYSICAL  EXAMINATION  OF  THE  HEART.  189 

in  width,  and  nearly  the  same  in  height,  is  known  as  the  area  of  super- 
ficial cardiac  dulness.  It  might  appropriately  be  called  the  area  of 
cardiac  flatness.  The  apex  of  this  triangle  is  at  the  centre  of  the  ster- 
num, nearly  on  a  line  with  the  fourth  rib;  the  base  corresponds  to  the 
costal  cartilage  of  the  sixth  rib. 

This  space  is  altered  in  extent  by  various  diseases  of  the  heart  and 
the  lungs.  Its  area  is  usually  increased  by  all  those  affections  which 
cause  enlargement  of  the  heart,  as  hypertrophy  and  dilatation,  or  simple 
hypertrophy. 

In  some  cases  of  hypertrophy,  an  emphysematous  condition  of  the  lung  more 
than  counterbalances  the  enlargement  of  the  heart,  and  thus  the  space,  instead 
of  being  increased,  is  diminished. 

This  area  is  also  increased  by  effusions  of  fluid  into  the  pericardial 
sac. 

Normally,  the  area  is  increased  by  forced  expiration,  and  diminished 
by  deep  inspiration. 

The  area  of  superficial  cardiac  dulness  is  diminished  by  emphysema, 
which  crowds  the  anterior  border  of  the  left  lung  over  the  heart,  and  by 
pneumothorax;  it  is  obliterated  in  the  rare  disease  known  as  pneumo- 
pericardium, in  which  air  or  gas  collects  in  the  pericardial  sac,  and  the 
normal  dulness  is  supplanted  by  tympanitic  resonance. 

The  area  of  deep-seated  cardiac  dulness  corresponds  to  the  borders  of 
the  heart.  It  extends  normally  from  the  third  rib  above  to  the  resonance 
of  the  stomach  below;  and  laterally  from  about  three-fourths  of  an 
inch  to  the  right  of  the  sternum  to  within  half  an  inch  of  the  left  nip- 
ple. This  area  of  dulness  is  increased  in  those  affections  which  cause 
enlargement  of  the  heart,  as  hypertrophy  and  dilatation,  and  by  peri- 
cardial effusions. 

When  the  dulness  is  first  increased  in  the  upper  portion  of  the  prse- 
cordial  space  above  the  third  ribs,  we  may  be  almost  certain  that  there 
is  pericardial  effusion,  for  an  increase  in  the  vertical  diameter  of  this 
area  is  seldom  found  in  disease  of  the  heart  itself. 

The  area  of  cardiac  dulness  is  apparently  increased  by  consolidation 
of  the  left  lung. 

The  outlines  of  the  heart  may  be  traced  a  little  more  easily  by  auscultatory 
percussion  than  by  the  ordinary  method  of  percussing.  In  practising  this  method, 
we  may  employ  either  the  solid  stethoscope  made  for  this  purpose,  or  the 
ordinary  binaural  stethoscope  with  the  small  chest-piece.  In  either  case  the 
chest-piece  should  be  placed  over  the  most  superficial  part  of  the  heart,  and  per- 
cussion should  be  made  from  the  resonant  portion  of  the  lungs  toward  the  cen- 
tral portion  of  the  heart,  from  above  downward  and  laterally  from  without  in- 
ward. By  this  method,  as  soon  as  the  outer  limits  of  the  pericardium  are 
reached,  the  change  in  the  percussion  note  is  at  once  perceptible  to  the  listener. 

In  auscultation  over  the  heart,  accurate  information  cannot  usually 
be  obtained  by  the  unaided  ear;  but  by  mediate  auscultation,  especially 


190  THE  HEART. 

if  the  small  chest-piece  of  the  stethoscope  be  used,  most  satisfactory 
results  can  be  secured. 

The  patient  should  be  in  the  recumbent  position  during  at  least  a  por- 
tion of  the  examination,  which  should  be  commenced  while  the  individual 
is  breathing  naturally.  Subsequently,  the  patient  should  be  directed  to 
take  three  or  four  deep  inspirations,  which  will  enable  us  more  clearly 
to  detect  sounds  that  are  produced  by  the  lungs.  Then  he  should  hold 
his  breath  for  a  few  seconds,  which  will  enable  us  to  eliminate  pulmo- 
nary sounds,  and  will  render  the  heart-signs  more  distinct. 

The  examination  must  not  stop  with  the  precordial  space,  but 
should  be  carried  over  the  entire  chest,  and  the  various  points  must  be 
localized  at  which  the  heart  sounds,  both  normal  and  abnormal,  may 
be  heard  most  distinctly.  It  is  not  the  point  at  which  the  sound  may 
be  heard  which  is  of  diagnostic  importance,  but  the  point  at  wTiicTt  it  is 
loudest. 

CAUSE    OF    THE    HEART    SOUNDS. 

Considerable  difference  of  opinion  exists  regarding  the  cause  of  the 
heart  sounds.  All  concede  that  the  second  sound  is  usually  produced  by 
closure  of  the  semi-lunar  valves;  and  it  is  generally  admitted  that  several 
elements  enter  into  the  production  of  the  first  sound,  though  the  im- 
portance of  each  of  these  is  variously  estimated  by  different  authors. 

The  main  factors  in  the  production  of  the  first  sound  are:  first,  the 
closure  of  the  mitral  and  the  tricuspid  valves;  second,  the  contraction 
of  the  muscular  fibres  of  the  heart;  third,  the  impulse  of  the  apex 
against  the  chest  walls.  Besides  these  elements,  friction  of  the  blood 
against  the  inner  surface  of  the  heart,  and  of  the  heart  against  the  sur- 
rounding tissues,  evidently  plays  some  part  in  forming  this  sound.  I 
believe  that  the  contraction  of  the  muscular  fibers  is  a  much  more  im- 
portant factor  in  the  production  of  the  first  sound  than  is  generally 
supposed. 

The  influence  of  the  contraction  of  the  muscular  fibres  may  be  shown  by  the 
following  simple  experiment.  Place  the  end  of  the  stethoscope  over  the  body 
of  a  muscle  which  can  be  contracted  or  relaxed  without  moving  the  integuments, 
as,  for  example,  upon  the  ball  of  the  thumb ;  flex  and  extend  the  terminal 
phalanx  regularly  about  seventy  times  a  minute  and  one  will  hear  what  almost 
seems  to  be  the  heart  beating  immediately  beneath  the  instrument.  Skoda  states 
that  the  heart  sounds  may  be  produced  by  the  arteries,  and  it  appears  to  follow 
with  tolerable  certainty  that  both  ventricles,  the  pulmonary  artery,  and  the  aorta 
are  capable,  each  separately,  of  producing  both  the  first  and  second  sounds  percep- 
tible in  the  region  of  the  heart. 

In  health,  the  first  sound  of  the  heart  is  dull,  soft,  and  prolonged,  as 
compared  with  the  second,  and  is  synchronous  with  the  systole  of  the 
heart,  the  apex  beat,  and  carotid  pulse.  Its  point  of  maximum  intensity 
corresponds  to  the  apex  beat. 

The  second  sound  of  the  heart,  which  is  dependent  upon  closure  of 


MODIFICATIONS  OF  THE  HEART  SOUNDS  BY  DISEASE.     191 

the  semi-lunar  valves,  caused  by  resilience  of  the  arteries,  is  shorter, 
sharper,  and  more  superficial  than  the  first,  and  possesses  none  of  that 
muscular  element  observed  in  the  latter.  It  coincides  with  the  diastole 
of  the  heart  and  follows  the  arterial  pulse  and  apex  beat.  Its  poir.t  of 
greatest  intensity  is  at  the  articulation  of  the  left  third  costal  cartilage 
with  the  sternum.  Immediately  following  the  second  sound  is  the 
period  of  silence,  which  varies  in  duration  with  the  rapidity  of  the 
heart's  action. 

The  extent  of  the  area  over  which  the  cardiac  sounds  may  be  heard 
will  vary  with  the  adaptability  of  the  surrounding  organs  for  transmit- 
ting sounds.  If  the  lungs  are  solidified,  the  sounds  may  be  heard  much 
farther  than  in  the  normal  condition ;  but  if  the  lungs  are  emphysema-- 
tous,  the  sounds  are  not  heard  as  far  as  in  health. 

Usually  the  sounds  produced  upon  the  right  side  are  heard  loudest 
over  the  corresponding  portion  of  the  heart,  and  toward  the  right  side 
of  the  sternum;  while  those  produced  upon  the  left  are  heard  loudest 
over  the  left  side  of  the  heart,  and  nearer  the  left  nipple. 

As  a  rule,  the  heart  sounds  are  louder  in  children  and  in  those  with 
thin  chest  walls  than  in  adults  or  in  those  with  the  parietes  very  mus- 
cular or  thickened  by  adipose  tissue.  The  intensity  varies  in  different 
individuals  with  the  changing  force  of  the  impulse  and  the  conforma- 
tion of  the  chest  walls,  and  with  peculiar  idiosyncrasies,  which  we  can- 
not well  understand. 

Hence,  we  recognize  the  necessity  of  studying  a  large  number  of 
healthy  hearts,  for  no  one  individual  can  be  taken  as  a  standard. 

MODIFICATIONS   OF    THE   HEART    SOUNDS    BY    DISEASE. 

The  heart  sounds  are  modified  by  disease,  in  their  intensity,  pitch, 
quality,  seat,  and  rhythm.  They  may  be  preceded,  accompanied,  or 
followed  by  abnormal  sounds  known  as  murmurs;  or  murmurs  may 
entirely  supplant  them. 

The  intensity  of  the  heart  sounds  is  increased  by  hypertrophy  of  the 
ventricles,  nervous  irritability,  cardiac  palpitation,  consolidation  of  ad- 
jacent luug  tissue,  and,  exceptionally,  by  dilatation  of  the  heart.  The 
intensity  of  these  sounds  is  diminished  by  simple  dilatation  "of  the  ven- 
tricles, by  fatty  degeneration  of  the  muscular  fibres  of  the  heart,  or  by 
deposition  of  fat  between  them  or  on  the  surface  of  the  organ,  by  soft- 
ening or  debility  of  the  muscular  fibres  as  the  result  of  protracted  dis- 
ease, for  example,  typhus  or  typhoid  fever,  and  by  pericardial  effusions. 
It  is  also  diminished  by  pulmonary  emphysema.  The  heart  sounds  are 
sometimes  masked  by  bronchial  rales. 

The  quality  of  the  heart  sounds  is  considerably  altered  in  a  great 
variety  of  diseases.  The  sounds,  instead  of  being  clear  and  distinct,  as 
in  typical  healthy  cases,  may  be  slightly  muffled,  or  they  may  be  associ- 
ated with  an  indistinct  and  transient  sound  which  closely  resembles  a 


192  THE  HEART. 

murmur.  This  imparity  of  the  heart  sounds,  unless  associated  with 
other  signs  of  cardiac  disease,  is  of  no  diagnostic  importance,  because  it 
very  frequently  occurs  as  the  result  of  pulmonary  disease  when  the 
heart  is  in  no  way  involved,  and  it  is  often  noticed  in  healthy  indi- 
viduals. 

The  first  sound  of  the  heart  is  rendered  duller  and  lower  in  pitch 
than  natural,  by  hypertrophy  of  the  ventricles,  with  thickening  of  the 
tricuspid  and  mitral  valves.  The  second  sound  is  modified  in  the  same 
way  by  thickening  of  the  semi-lunar  valves  without  regurgitation,  and  by 
loss  of  elasticity  in  the  arterial  walls. 

The  first  sound  of  the  heart  is  sharper  and  higher  pitched  than  nor- 
mal in  dilatation  of  the  ventricles  without  alteration  of  the  auriculo- 
ventricular  valves. 

The  second  sound  of  the  heart  may  be  higher  pitched  than  natural, 
or,  in  other  words,  accentuated,  at  either  the  aortic  or  the  pulmonary 
orifice. 

At  the  aortic  orifice,  this  sound  is  somewhat  intensified  by  hyper- 
trophy of  the  left  ventricle,  due  to  obstruction  in  the  artery.  A  ventri- 
cle thus  hypertrophied  propels  the  blood  with  increased  force  into  the 
aorta,  unduly  distends  this  vessel,  and  thus  causes  sudden  and  more 
forcible  contraction  of  the  artery,  with  a  sharper  sound  from  the  semi- 
lunar valves.  "Well-marked  accentuation  of  the  second  sound  in  this 
position  results  from  setting  back,  on  the  valves,  of  an  increased  volume 
of  blood,  and  it  is  always  caused  by  dilatation  of  the  aorta. 

Accentuation  of  the  second  sound  at  the  pulmonary  orifice  occurs  in 
a  great  variety  of  diseases.  It  is  the  most  persistent  of  all  the  signs  of 
cardiac  disease,  but  it  is  also  found  in  nearly  every  case  of  pulmonary 
congestion  from  whatever  cause.  Whenever  there  is  obstruction  or  re- 
gurgitation at  the  mitral  orifice,  there  must  be  increased  tension  of  the 
blood  in  the  left  auricle  and  in  the  pulmonary  veins,  which  will  be 
transmitted  through  the  short  pulmonary  circuit  back  to  the  pulmo- 
nary artery.  This  will  cause  a  sudden  and  sharper  closure  of  the  valves 
which  guard  the  outlet  of  the  right  ventricle.  Obstruction  in  the  pul- 
monary circuit  from  disease  of  the  lungs,  by  inducing  hypertrophy  and 
dilatation  of  the  right  ventricle,  causes  extreme  distention  of  the  pul- 
monary artery  with  each  pulsation,  and  consequent  accentuation  of  the 
second  sound  in  the  pulmonary  area. 

The  heart  sounds  become  metallic  or  tinkling  in  quality  in  irritable 
conditions  of  the  organ  and  when  the  stomach  is  distended  with  gas. 

Exceptional. — The  heart  sounds  are  very  metallic  in  character  in  the  rare 
disease  known  as  pneumo- pericardium.  They  are  sometimes  metallic  in  left- 
sided  pneumothorax.  The  same  character  is  sometimes  noticed  with  the  second 
sound,  at  the  aortic  orifice,  when  there  is  atheroma  of  this  vessel  limited  to  its 
initial  portion. 

The  seat  of  the  heart  sounds  is  a  limited  space  in  which  they  can  be 


MODIFICATION  OF  THE  HEART  SOUNDS  BY  DISEASE.      193 

heard  most  distinctly.  It  may  be  altered  by  several  diseases.  The 
sounds  obtainable  over  the  apex  are  heard  above  their  normal  position, 
whenever  the  abdominal  organs  are  so  enlarged  as  to  encroach  upon  the 
thoracic  cavity,  as  in  distention  of  the  stomach,  or  enlargement  of  the 
liver,  or  ascites,  or  large  ovarian  tumors.  They  are  also  heard  above 
their  normal  position  when  effusion  is  present  in  the  pericardial  sac. 

These  sounds  are  heard  below  their  usual  seat  when  the  apex  is 
depressed  by  mediastinal  tumors,  or  by  hypertrophy  with  dilatation  of 
the  auricles.  They  are  displaced  laterally  by  pleuritic  effusions,  pneu- 
mothorax, and  by  deformities  of  the  chest.  They  are  displaced  to  the 
left  whenever  the  heart  is  enlarged,  whether  by  hypertrophy  or  by  dila- 
tation, or  when  it  is  drawn  from  its  position  by  contracting  adhesions. 

The  rhythm  of  the  heart  sounds  is  altered  by  many  diseases. 

Frequently  the  heart  acts  regularly  for  some  time,  and  then  drops 
one  or  more  beats  to  go  on  again  with  its  regular  pulsations.  This  is 
known  as  an  intermittent  rhythm. 

If  the  intermittent  rhythm  includes  the  period  of  one  pulsation  only, 
it  is  of  no  special  importance,  as  such  phenomena  occur  under  a  variety 
of  circumstances,  independent  of  cardiac  disease;  it  is  a  curious  fact 
that  intermission  in  the  heart's  action  often  occurs  in  some  people  just 
preceding  a  thunder-storm.  But  if  this  intermission  occupies  the  time 
of  two  or  three  pulsations,  and  if  the  heart's  action  is  irregular — that  is, 
beating  rapidly,  then  slowly,  finally  intermitting,  and  then  starting  up 
with  rapid  pulsations,  as  if  to  make  up  for  lost  time — it  is  a  sign  of  car- 
diac disease. 

The  first  sound  of  the  heart  is  prolonged  by  hypertrophy  of  the  ven- 
tricles, and  by  agglutination  of  the  surfaces  of  the  pericardium.  It  is 
shortened  in  dilatation  of  the  ventricles,  and  both  sounds  are  shortened 
by  fatty  degeneration  and  softening  of  the  heart  walls. 

The  period  of  repose  is  sometimes  prolonged  by  obstruction  to  the 
onward  flow  of  the  blood  into  the  left  ventricle,  owing  to  stenosis  of  the 
mitral  orifice. 

Eeduplication"  of  sounds,  another  alteration  of  the  rhythm,  con- 
sists of  a  repetition  of  one  or  both  of  the  heart  sounds  during  a  single 
pulsation,  so  that  three  or  four  sounds  may  be  heard  with  each  contrac- 
tion of  the  heart.  Ordinarily,  the  right  and  left  sides  of  the  heart  con- 
tract at  exactly  the  same  time,  and  consequently  the  sounds  which  are 
produced  in  the  two  cannot  be  distinguished;  but  occasionally  there  is  a 
slight  interval  between  the  closure  of  the  valves  at  the  auriculo-ventric- 
ular  or  at  the  arterial  orifices  of  the  two  sides,  so  that  the  sounds  do  not 
occur  simultaneously,  and  thus  the  first  sound  may  be  doubled,  the 
second  sound  remaining  natural;  or  the  second  sound  may  be  doubled, 
the  first  remaining  single;  or  both  may  be  doubled. 

This  phenomenon  occurs  in  diseases  of  the  heart,  but  may  often  be 
discovered  in  health,  if  searched    for  with  the  differential   stethoscope 


194  THE  HEART. 

(Fig.  15).  When  occurring  in  disease,  reduplication  is  usually- 
caused  by  stenosis  of  the  mitral  orifice  or  incompetence  of  its  valves. 
This  gives  rise  to  increased  tension  in  the  pulmonary  circuit  and  to 
abrupt  closure  of  the  pulmonary  semilunar  valves,  which  thus  slightly 
anticipates  the  closure  of  the  aortic  valves,  and  causes  reduplication  of 
the  second  sound. 

Reduplication  of  the  first  sound  is  due  to  tardy  closure  of  the  mitral 
valves.  Some  care  will  be  necessary  to  avoid  mistaking  reduplication 
for  endocardial  murmurs  which  precede  or  follow  the  normal  sounds. 
Intermission  is  a  characteristic  of  reduplication  (Loomis'  Physical 
Diagnosis).  In  some  cases  reduplication  is  influenced  by  the  acts  of 
respiration.  In  forced  or  laborious  respiration,  the  first  sound  may  be 
reduplicated  at  the  end  of  inspiration  and  at  the  beginning  of  expira- 
tion ;  the  second  sound  may  be  reduplicated  at  the  end  of  expiration  and 
at  the  beginning  of  inspiration. 


CHAPTEK   XII. 

THE   HEART.— Continued. 

ABNORMAL  SOUNDS— CARDIAC  MURMURS. 

The  abnormal  sounds  heard  over  the  precordial  region  are  denom- 
inated murmurs.  Sometimes  these  are  produced  upon  the  surface  of 
the  heart,  between  the  two  layers  of  the  pericardium,  but  most  of  them 
originate  within  the  heart.  The  latter  are  known  as  endocardial  and 
the  former  as  exocardial  murmurs. 

The  exocardial  or  pericardial  friction  sounds  or  murmurs 
are  produced  by  the  rubbing  together  of  the  roughened  surfaces  of  the 
pericardium,  in  the  same  manner  that  friction  sounds  are  produced 
within  the  pleura.  These  murmurs  vary  greatly  in  their  intensity  and 
quality.  Sometimes  they  are  very  indistinct,  at  others  loud.  In  quality, 
they  may  be  grazing,  grating,  rubbing,  creaking,  or  crackling,  like 
pleuritic  friction  sounds. 

The  quality  of  an  exocardial  murmur  yields  no  information  regard- 
ing the  peculiar  condition  of  the  surface  which  produces  it,  though,  in 
the  dry  stage  of  pericarditis,  the  grazing  sound  is  the  one  most  likely  to 
be  heard. 

These  murmurs  may  be  either  single  or  double;  that  is,  they  may 
occur  with  the  systole  or  with  the  diastole  of  the  heart,  or  with  both. 
They  sometimes  accompany  the  valvular  sounds;  at  other  times  they 
are  independent  of  them.  They  are  always  superficial  in  character  and 
they  seem  to  be  produced  immediately  beneath  the  chest  walls.  The  area 
over  which  they  can  be  heard  is  restricted  to  the  precordial  space.  They 
are  generally  heard  loudest  at  the  junction  of  the  fourth  left  costal  car- 
tilage with  the  sternum.  They  generally  last  for  only  a  few  hours,  sel- 
dom longer  than  one  or  two  days,  and  then  disappear  in  consequence  of 
the  exudation  of  serum  into  the  pericardium.  As  the  serous  effusion 
becomes  absorbed  in  the  later  stage  of  pericarditis,  the  friction  murmur 
may  reappear. 

Pericardial  friction  sounds  are  distinguished  from  endocardial  mur- 
murs :  first,  by  their  superficial  character;  second,  by  being  limited  to  the 
precordial  space,  i.e.,  never  being  transmitted  to  the  left  of  the  apex,  or 
above  the  base  of  the  heart;  third,  by  their  being  independent  of  valvular 
sounds ;  and  fourth,  by  the  variation  in  their  intensity  with  changes  in 
the  position  of  the  patient.     When  the  patient  is  in  the  erect  or  in  the 


196  THE  HEART. 

recumbent  posture,  the  heart  does  not  approach  so  near  to  the  surface 
of  the  chest  as  when  he  is  leaning  well  forward,  and  therefore  the  sounds 
are  not  as  distinct.  In  general,  the  intensity  is  greater  during  expira- 
tion than  during  inspiration. 

Pericardial  friction  sounds  are  distinguished  from  pleuritic  friction 
sounds  by  their  confinement  to  the  praecordia,  by  their  synchronism 
with  the  cardiac  movements  instead  of  the  respiration,  and  by  continu- 
ance during  temporary  suspension  of  the  respiratory  act. 

Exceptional. — It  should  be  remembered  that,  in  some  cases  of  pleurisy,  rub- 
bing- of  the  fibrous  layer  of  the  pericardium  against  an  inflamed  pleura  gives  rise 
to  a  friction  sound  having  the  same  rhythm  as  the  heart,  and  continuing  while 
respiration  is  suspended.  Such  a  sign  is  called  a  cardio-pleuritic  friction  viur- 
mur.  It  is  easily  mistaken  for  the  pericardial  murmur,  but  its  cause  should 
always  be  suspected  when  other  signs  of  pleurisy  exist,  especially  if  the  pleurisy 
be  associated  with  pneumonia.  This  sound  differs  from  the  pericardial  murmur 
in  the  uniformity  in  intensity  of  the  successive  sounds,  in  its  limitation  to  the 
border  of  the  heart,  and,  in  some  cases  to  the  end  of  inspiration,  and  in  gen- 
erally being  affected  to  a  greater  or  less  degree  by  "the  movements  of  inspiration. 

Endocardial  murmurs  vary  in  their  intensity,  pitch,  and  quality; 
but  these  elements  are  of  very  little  importance  from  a  diagnostic  point 
of  view,  as  the  intensity  and  the  pitch  of  the  sounds  yield  us  no  infor- 
mation whatever,  and  the  quality  is  never  characteristic,  except  in  the 
presystolic  murmur  due  to  stenosis  of  the  mitral  orifice. 

These  sounds  are  produced  by  changes  in  the  physical  condition  of 
the  heart,  in  which  case  they  are  known  as  organic  murmurs;  or  by 
changes  in  the  condition  of  the  blood,  when  they  are  termed  inorganic, 
anaemic,  or  haemic  murmurs. 

Organic  murmurs  are  usually  permanent,  though  not  infrequently 
they  cease  for  a  considerable  length  of  time,  and  in  some  cases  they 
may  entirely  disappear.  The  inorganic  murmurs  are  transitory — present 
for  a  few  hours  or  days  and  then  disappearing  permanently,  or  to  recur 
after  a  short  interval.  Sometimes  they  come  and  go  while  the  exami- 
nation is  being  made. 

A  murmur  in  the  precordial  space  indicates  nothing  except  a  dis- 
turbance of  the  normal  relations  of  the  heart  to  the  blood,  and  may  be 
due  to  a  change  in  the  physical  condition  of  the  heart  itself  or  in  the 
normal  composition  of  the  blood,  or  it  may  result  from  irregular tcon- 
tractions  of  the  cardiac  muscle. 

The  important  things  to  note  regarding  a  murmur  are:  first,  the 
seat;  second,  the  rhythm;  and  third,  the  quality.  The  direction  in 
which  the  sound  is  most  clearly  transmitted  is  also  an  essential  feature 
in  diagnosis. 

In  noting  the  rhythm,  we  observe  the  relation  of  the  murmur  to  the 
systole  and  the  diastole  of  the  ventricles,  and  we  ascertain  whether  it 
precedes,  accompanies,  or  follows  the  first  or  second  sound  of  the  heart. 


CARDIAC  MURMURS.  197 

In  a  few  instances,  the  peculiar  quality  of  the  sound  itself  is  im- 
portant. Some  murmurs  are  grating,  others  blowing  or  rushing  in 
quality,  and  others  are  harsh,  or  soft,  or  musical.  A  murmur  may  hare 
many  of  these  characteristics  at  different  times  without  any  appreciable 
change  in  the  conditions  which  produce  it. 

Whenever  we  hear  an  abnormal  sound  in  the  precordial  space,  we 
should  ascertain,  by  careful  examination,  its  point  of  maximum  intensity, 
whether  it  is  synchronous  with  either  the  contraction  or  the  dilatation 
of  the  cardiac  cavities  and  depends  upon  the  current  of  blood  through 
the  valvular  orifices,  or  whether  it  is  produced  outside  the  heart.  As 
the  majority  of  abnormal  cardiac  sounds  are  produced  within  the  heart, 
the  presumption  is  always  that  a  murmur  is  endocardial;  if  we  should 
find  it  comparatively  deep  seated,  and  synchronous  with  the  systole  or 
the  diastole  of  the  ventricles,  and  transmitted  to  the  left  of  the  apex, 
or  above  the  base  of  the  heart,  we  may  safely  conclude  that  it  belongs 
to  this  class. 

"When  we  remember  that  nearly  all  endocardial  murmurs  are  pro- 
duced at  one  of  the  valvular  orifices,  and  that  these  approximate  so 
closely  to  each  other  that  a  circle  half  an  inch  in  diameter  may  include 
a  portion  of  each,  it  is  at  once  apparent  that  it  must  be  impossible  to 
distinguish  between  different  endocardial  sounds  by  listening  for  them 
directly  over  their  point  of  origin. 

Sound  loses  its  intensity  by  passing  from  one  medium  to  another,  as 
will  occur  in  the  passage  of  sound  from  one  cavity  of  the  heart  to  an- 
other, and  any  sound  produced  by  fluid  in  motion  is  transmitted  in  the 
direction  of  the  current  which  causes  it.  A  knowledge  of  these  two  facts 
will  aid  us  greatly  in  differentiating  between  endocardial  sounds.  We 
shall  find  that,  as  a  rule,  sounds  produced  in  any  of  the  cavities  of  the 
heart,  or  transmitted  into  them,  are  best  heard  over  the  space  where 
that  cavity  is  most  superficial.  For  example,  the  only  point  at  which 
the  left  ventricle  impinges  directly  on  the  chest  wall  is  where  the  apex 
beat  is  felt;  murmurs  produced  at  its  auricular  orifice  are  best  heard  at 
this  spot,  while  those  at  the  tricuspid  orifice  are  most  distinct  over  that 
portion  of  the  right  ventricle  which  is  superficial.  The  murmurs  at  the 
aortic  and  pulmonary  orifices  are  respectively  heard  with  the  greatest 
distinctness  where  these  arteries  approach  nearest  the  chest  wall. 

Some  of  the  endocardial  murmurs,  however,  are  produced  by  blood 
flowing  in  an  abnormal  direction.  Therefore,  the  areas  in  which  mur- 
murs produced  at  the  various  orifices  are  most  distinct  will  not  always 
exactly  correspond  to  the  positions  in  which  the  normal  sounds  are 
loudest. 

Before  examining  the  heart  by  auscultation,  we  should  ascertain  its 
superior  and  lateral  limits  by  percussion  or  by  auscultatory  percussion, 
and,  either  by  these  methods  or  by  palpation,  determine  the  position  of 
the  apex. 


198 


THE  HEART. 


The  mitral  area,  as  the  space  is  named  where  the  mitral  sounds  may 
be  heard  with  maximum  intensity,  corresponds  to  a  circle  two  inches  in 
diameter,  which  includes  the  apex  of  the  heart  (A,  Fig.  33).  If  this 
organ  is  in  its  normal  position,  the  circle,  as  shown  in  the  diagram,  will 
have  its  centre  near  the  normal  position  of  the  apex  beat;  but  if,  from 
enlargement  or  other  causes,  the  heart  is  displaced  to  the  left,  the  posi- 
tion of  this  circle  is  correspondingly  changed. 

Mitral  murmurs,  if  caused  by  regurgitation,  are  also  heard  diffused 
for  a  distance  varying  from  one  to  three  inches  to  the  left  of  the  apex. 
Often  they  may  be  heard  behind,  along  the  left  side  of  the  sixth  and 
seventh  dorsal  vertebrae,  with  nearly  the  same  intensity  as  in  front; 


Fig, 


33.— Areas  of  Endocardial  Murmurs.      A,  Mitral  area  ;   B,  aortic  area  ;    C.  tricuspid  area  ; 

D,  pulmonary  area. 


sometimes  they  may  be  heard  in  this  position  when  they  are  not  distinct 
in  front. 

Cure  must  be  taken  not  to  confound  mitral  murmurs  with  aortic  regurgitant 
murmurs,  which  are  occasionally  heard  at  the  lower  angle  of  the  left  scapula, 
and  in  the  left  axillary  region  ;  or  with  aneurismal  murmurs,  which  may  also  be 
heard  along  the  left  side  of  the  spinal  column,  in  the  same  position  as  the  mitral 
regurgitant  murmur. 

A  mitral  regurgitant  murmur  differs  from  an  aneurismal  murmur  in 
being  heard  behind  only  between  the  fifth  and  the  eighth  dorsal  vertebrae. 
The  aneurismal  murmur  may  be  heard  above  the  fifth  vertebra,  and,  with 
diminished  intensity,  below  the  eighth  as  well  as  between  the  two. 

An  aortic  direct  murmur,  heard  behind,  should  not  be  mistaken  for 
a  mitral  regurgitant  murmur,  since  it  is  heard  loudest  above  the  lower 
border  of  the  fifth  dorsal  vertebra. 

Mitral  regurgitant  murmurs  may  sometimes  disappear,  even  though  due  to 
organic  lesions.  In  such  cases,  accentuation  of  the  second  sound  at  the  pulmo- 
nary orifice  may  be  the  only  abnormal  sign  remaining. 


CARDIAC  MURMURS.  19& 

If  a  mitral  murmur  is  obstructive,  or  direct,  i.e.,  due  to  stenosis  of 
the  mitral  orifice,  it  will  be  heard  at  the  apex,  but  will  not  be  distinctly 
transmitted  to  the  left,  and  will  not  be  heard  behind. 

It  is  to  be  borne  in  mind  that,  in  speaking  of  the  areas  of  murmurs, 
we  refer  only  to  the  positions  at  which  they  may  be  heard  with  the 
greatest  intensity.  Sometimes  a  mitral  murmur  may  be  heard  over  the 
whole  precordial  region,  or  even  over  the  entire  chest,  but  its  point  of 
maximum  intensity  will  correspond  to  the  area  which  we  have  just 
described. 

The  tricuspid  area  of  murmurs  is  limited  to  the  triangular  space  (C, 
Fig.  33)  where  the  right  ventricle  is  superficial.  These  murmurs  are 
ordinarily  loudest  over  the  xiphoid  cartilage,  or  along  the  left  border  of 
the  sternum,  at  the  junction  of  the  sixth  or  seventh  costal  cartilage, 
and  are  seldom  audible  above  the  third  rib.  This  latter  feature  distin- 
guishes them  from  aortic  and  pulmonic  murmurs.  When  the  heart  is 
hypertrophied  or  dilated,  their  intensity  will  sometimes  be  greatest  at  the 
junction  of  the  fourth  costal  cartilage  with  the  sternum.  These  mur- 
murs are  superficial  in  character  as  compared  with  those  occurring  upon 
the  left  side  of  the  heart.  If  transmitted  in  any  direction,  they  will  be 
heard  more  distinctly  to  the  right  than  to  the  left  of  the  parasternal  line. 

The  pulmonary  area  of  murmurs  corresponds  to  a  small  circle  about 
an  inch  in  diameter,  located  just  above  the  third  costal  cartilage  at  the 
left  border  of  the  sternum,  and  covering  the  pulmonary  artery  (~D, 
Fig.  33).  Pulmonic  murmurs  are  heard  most  distinctly  directly  over 
the  pulmonary  artery.  These  sounds  are  never  heard  in  the  carotid 
and  subclavian  arteries.  If  due  to  regurgitation  through  the  pulmo- 
nary valves  into  the  right  ventricle,  they  may  be  most  intense,  an  inch 
or  an  inch  and  a  half  below  this  area,  near  the  left  margin  of  the 
sternum.  They  are  not  heard  at  the  apex,  and  this  distinguishes  them 
from  some  aortic  murmurs.  These,  like  the  tricuspid  murmurs,  are 
comparatively  superficial. 

The  aortic  area  of  murmurs  cannot  be  so  sharply  defined  as  the  areas 
of  the  murmurs  we  have  just  described.  Aortic  murmurs  are  usually 
loudest  in  the  second  intercostal  space  of  the  right  side,  where  the  artery 
approaches  most  closely  to  the  thoracic  walls;  or  along  the  right  margin 
of  the  sternum  from  the  second  to  the  fourth  rib;  but  they  are  often 
heard  over  the  whole  sternum  {B,  Fig.  33). 

Aortic  murmurs  are  propagated  to  the  carotid  or  subclavian  arteries, 
and  are  frequently  heard  best  in  these  localities.  Occasionally  they  are 
louder  in  the  pulmonary  area  than  at  any  other  point.  In  such  in- 
stances they  are  distinguished  from  pulmonary  murmurs  by  being  heard 
also  in  the  arteries  at  the  base  of  the  neck.  Aortic  murmurs  are  often 
heard  behind,  along  the  left  side  of  the  third  and  fourth  dorsal  verte- 
bras, and  with  diminishing  intensity  for  a  considerable  distance  down  the 
spine.     They  are  frequently  very  distinct  at  the  apex  of  the  heart. 


200  THE  HEART. 

Aortic  regurgitant  murmurs  are  often  loudest  over  the  lower  part  of 
the  sternum,  though  we  expect  to  find  them  most  distinct  a  short  dis- 
tance below  the  aortic  valves.  These  murmurs  are  frequently  audible  in 
the  left  axillary  region,  and  at  the  lower  angle  of  the  scapula.  The 
patient  may  often  hear  them  himself,  especially  when  lying  down. 

Exceptional. — Aortic  murmurs  may  sometimes  be  heard  over  the  arteries 
when  they  are  not  distinct  at  the  base  of  the  heart.  At  other  times  they  are 
audible  at  the  base  of  the  heart  only  ;  and  still  again,  they  may  be  distinct  over 
the  entire  precordial  region. 

Regurgitant  aortic  murmurs  are  frequently  heard  in  all  the  arteries 
which  are  accessible  to  auscultation.  It  should  be  remembered  that  the 
aortic  murmurs  are  the  only  ones  that  may  be  heard  above  the  clavicles. 

Both  the  obstructive  and  the  regurgitant  aortic  murmurs  vary  much 
in  intensity.  Sometimes  it  is  necessary  to  listen  intently  in  order  to 
hear  them  at  all.  In  other  cases  they  are  so  loud  that  they  may  be  heard 
at  some  distance  from  the  patient. 

The  rhythm  of  a  murmur  refers  to  the  relation  which  it  bears  to  the 
cardiac  pulsation,  and  consequently  to  the  first  and  second  sounds  of 
the  heart.  In  determining  the  rhythm  of  a  murmur,  we  must  first  as- 
certain which  is  the  first  and  which  the  second  sound  of  the  heart.  This 
will  not  be  a  difficult  task  if  the  heart  is  pulsating  slowly  and  both 
sounds  are  distinct;  for  we  know  that  the  first  sound  is  the  louder  and 
longer,  and  that  it  is  associated  with  the  impulse  of  the  apex  against  the 
chest  wall.  In  some  instances  only  one  of  the  valvular  sounds  can  be 
heard  at  the  apex  or  at  the  base,  and  in  such  cases  a  murmur  would 
very  naturally  be  mistaken  for  the  other  sound.  In  every  case  of  doubt 
we  must  feel  for  the  carotid  pulse,  which  is  always  synchronous  with  the 
first  sound  of  the  heart,  and  will  therefore .  enable  us  to  determine  the 
rhythm  of  the  murmur. 

The  quality  of  endocardial  murmurs  gives  us  no  information  regard- 
ing their  place  of  origin  or  the  conditions  which  produce  them,  except- 
ing in  cases  of  presystolic  mitral  murmurs,  which  will  be  presently  de- 
scribed, and  anaemic  murmurs,  which  are  always  soft  in  character. 

Causes  of  Endocardial  Murmurs. — Presystolic  mitral  and  tricuspid 
murmurs,  preceding  as  they  do  the  first  sound  of  the  heart,  must  occur 
while  the  blood  is  passing  from  the  auricles  into  the  ventricles,  and 
while  the  valves  are  thrown  out  upon  the  current  (Fig.  34).  They  are 
always  caused  by  narrowing  (stenosis)  of  the  auriculo-ventricular  orifice, 
which  obstructs  the  onward  flow  of  blood.  Such  a  murmur,  if  produced 
upon  the  left  side,  will  be  loudest  at  the  apex,  but  will  not  be  trans- 
mitted to  the  left  of  the  apex,  and  cannot  be  heard  behind.  It  is  called 
a  mitral  presystolic  or  obstructive  murmur.  This  is  perhaps  the  only 
murmur  where  the  quality  of  the  sound  is  of  any  special  diagnostic 
value.  According  to  Balfour,  the  quality  of  these  murmurs  is  charac- 
teristic, though  not  exactly  the  same  in  all  cases.     It  may  be  quite  ac- 


CA  RDIA  C '  MUEM  URS. 


201 


curately  represented  by  vocalizing  the  symbols  R  r  r  b  or  V  o  o  t.  If 
a  murmur  which  precedes  the  first  sound  of  the  heart  is  produced  upon 
the  right  side — which  is  extremely  uncommon — it  is  called  a  tricuspid 
obstructive  murmur,  and  its  area  is  limited  to  the  triangular  space  C,  at 
the  lower  portion  of  the  sternum  (Fig.  33). 

Systolic  murmurs,  or  murmurs  accompanying  or  following  the  first 
sound  of  the  heart,  must  occur  with  the  contraction  of  the  ventricles, 
the  closure  of  the  auriculo-ventricular  valves,  and  the  propulsion  of  the 
blood  from  the  ventricles  into  the  arteries.  They  may  be  due  to  lesions 
at  any  of  the  valvular  orifices. 

The  mitral,  systolic  or  regurgitant,  murmur  is  produced  at  the  mitral 
orifice,  and  is  due  to  thickening,  corrugation,  or  adhesion  of  the  valves, 
which  prevents  them  from  perfectly  closing  the  orifice,  and  thus  allows 


Fig.  34.—  Ackicttlak  Systole.     A,  C,  Contracted  auricles :  B,  D,  dilated  ventricles.    Mitral  and 
tricuspid  valves  open  ;  semilunar  valves  closed. 


the  blood  to  regurgitate  into  the  left  auricle.  It  may  also  result  from 
rupture  or  undue  shortening  or  stretching  of  the  columna?  carnea?  or 
their  tendons,  which  normally  keep  the  valves  from  giving  way  before 
the  column  of  blood.  This  murmur  is  generally  soft  and  blowing,  and 
may  be  musical  in  quality ;  it  will  be  loudest  in  the  mitral  area.  It  will 
be  transmitted  to  the  left  of  the  apex,  and  may  be  heard  posteriorly 
along  the  left  side  of  the  spinal  column  from  the  fifth  to  the  eighth 
dorsal  vertebra.  It  is  seldom  heard  in  this  situation  with  the  same  in- 
tensity as  at  the  apex,  but  occasionally  it  is  distinct  behind  when  it  is 
not  audible  in  front.  If  a  mitral  murmur  is  caused  simply  by  roughen- 
ing of  the  ventricular  surface  of  the  valves,  it  will  not  be  heard  beside 
the  sixth  or  seventh  dorsal  vertebra,  though  it  may  be  heard  about  the 
inferior  angle  of  the  scapula,  and  in  the  left  axillary  region. 

Sometimes  endocardial  murmurs  are  produced  by  dilatation  of  the 
ventricles,  which  prevents  perfect  closure  of  the  mitrai  valves.     Such 


202 


THE  HEART. 


murmurs  have  been  termed  curable  mitral  regurgitant  murmurs,  as 
they  disappear  when  the  tonicity  of  the  muscular  fibre  has  become  suffi- 
ciently restored  to  contract  the  cavities  to  their  original  size.  These 
murmurs  are  probably  caused  by  dilatation  of  the  ventricles  without  a 
corresponding  elongation  of  the  musculi  papillares  in  consequence  of 
which  the  chorda?  tendineae  are  too  short  to  allow  the  valves  to  close. 
The  tricuspid  systolic,  or  regurgitant,  murmur  will  be  heard  in  the  tri- 
cuspid area,  and  if  transmitted  in  either  direction  will  be  louder  to  the 
right  than  to  the  left.  It  will  not  be  heard  at  the  apex  distinctly,  and 
never  to  the  left  of  the  apex  or  behind.  This  murmur  has  generally  a 
blowing  quality. 

If  the  aortic  systolic,  obstructive  or  direct,  murmur  is  of  organic 
origin,  it  will  be  caused  by  constriction  of  the  aortic  semilunar  valves, 


Fig.  35.— Systole  of  the  Ventricles.    A,  C,  Auricles  dilating;  B,  D,  ventricles  contracting    Semi- 
lunar valves  open  ;  mitral  and  tricuspid  valves  closed. 

or  by  roughening  of  their  ventricular  surfaces,  or  possibly  by  disease  of 
the  artery.  It  will  be  produced  while  the  blood  is  passing  from  the 
ventricles  into  the  arteries  (Fig.  35),  and  will  be  heard  in  the  aortic  area 
over  the  second  intercostal  space  of  the  right  side,  or  over  other  por- 
tions of  the  sternum  as  shown  by  the  space  B  (Fig.  33).  It  will  also 
be  heard  in  the  arteries  of  the  neck,  and  frequently  at  the  left  of  the 
third  and  fourth  dorsal  vertebra?  posteriorly  and  possibly  with  dimin- 
ished intensity  farther  down  the  spine. 

If  this  murmur  is  loudest  over  the  pulmonary  artery,  as  occasionally 
happens,  it  may  be  distinguished,  from  murmurs  produced  at  the  pul- 
monary orifice,  by  the  fact  that  it  is  transmitted  to  the  carotid  and  sub- 
clavian arteries. 

A  systolic  murmur  produced  at  the  pulmonary  orifice  is  likely  to  be 
anaemic  murmur;  but  if  of  organic  origin,  it  is  usually  due  to  obstruc- 


CARDIAC  MURMURS.  203 

tion  similar  to  that  just  described  as  occurring  at  the  aortic  valves. 
These  murmurs  are  sometimes  caused  by  pressure  on  the  artery  from 
enlarged  glands;  or  by  constriction  of  the  artery  from  pleuritic  adhe- 
sions, or  fibroid  phthisis  with  contraction  of  the  lung.  Such  a  murmur 
will  be  heard  most  distinctly  in  the  pulmonary  area  {D,  Fig.  33), 
and  will  not  be  audible  in  the  arteries  at  the  base  of  the  neck. 

Diastolic  Murmurs. — A  murmur  accompanying  or  following  the 
second  sound  of  the  heart  occurs  with  the  diastole  of  the  ventricles, 
and  must  be  due  to  regurgitation  of  blood  from  the  arteries  through  the 
semilunar  valves,  on  either  the  right  or  the  left  side. 

If  a  murmur,  accompanying  or  following  the  second  sound  of  the 
heart,  occurs  at  the  aortic  orifice,  it  will  be  due  to  regurgitation  of  blood 
from  the  artery  into  the  left  ventricle,  and  may  be  called  aortic  diastolic  or 
regurgitant.  It  will  generally  be  soft  and  blowing  in  character,  though 
it  may  be  harsh.  It  will  be  heard  in  the  aortic  area,  but  usually  most 
distinctly  a  short  distance  below  the  valves ;  it  will  be  propagated  down 
the  sternum  and  it  may  sometimes  be  loudest  at  the  ensiform  appendix. 

Exceptional. — In  some  instances  such  murmurs  are  very  distinct  at  the  apex, 
in  the  axillary  region  about  the  lower  angle  of  the  left  scapula,  or  over  all  large 
superficial  arteries. 

If  produced  at  the  pulmonary  orifice,  a  diastolic  murmur  is  due 
to  regurgitation  through  the  pulmonary  valves,  and  is  called  a 
pulmonary  diastolic  or  regurgitant  murmur.  Such  murmurs  are  ex- 
tremely rare. 

"When  such  a  murmur  does  occur,  it  will  be  heard  in  the  pulmonary 
area,  or  an  inch  or  an  inch  and  a  half  below  this  space,  and  it  will  not 
be  transmitted  to  the  large  arteries  or  to  the  lower  part  of  the  sternum. 
By  this  latter  fact  it  may  easily  be  distinguished  from  a  similar  murmur 
at  the  aortic  orifice. 

Thus,  we  may  have  eight  distinct  valvular  murmurs,  four  of  which 
are  obstructive  and  four  regurgitant.  Two  of  these,  viz.,  the  regurgi- 
tant pulmonary  and  the  obstructive  tricuspid  murmurs,  are  so  very  rare 
that  their  existence  is  doubted  by  many  skilled  diagnosticians.  Regurgi- 
tant tricuspid  murmurs  are  rare  except  as  the  consequence  of  disease  of 
the  left  side  of  the  heart,  which  gives  rise  to  such  dilatation  of  the  right 
ventricle  that  the  auriculo-ventricular  orifice  becomes  too  large  to  be 
closed  by  the  tricuspid  valves. 

We  may  have  two  or  more  of  these  sounds  combined  in  any  case; 
thus,  it  is  not  uncommon  to  obtain  a  mitral  regurgitant  murmur  asso- 
ciated with  an  aortic  obstructive,  and  perhaps  also  with  an  aortic 
regurgitant  murmur;  or  we  may  have  both  the  mitral  obstructive  and 
regurgitant,  with  the  aortic  obstructive  and  regurgitant  murmur. 

Murmurs  are  common  in  the  left  side  of  the  heart,  but  rare  in  the 
right  side. 


204  THE  HEART. 

According  to  my  observation,  the  various  murmurs  occur  in  the  fol- 
lowing order  of  frequency :  mitral  regurgitant,  aortic  regurgitant,  aortic 
obstructive,  mitral  obstructive  or  presystolic,  and  tricuspid  regurgitant. 

Ventricular  Murmurs. — There  are  certain  murmurs  occasionally 
heard  in  the  pra?cordial  region,  which  are  neither  of  valvular  nor  of 
haemic  origin.  They  are  most  frequent  during  the  acute  stage  of  en- 
docarditis, but  they  also  occur  in  chronic  endocarditis.  They  some- 
times precede  and  sometimes  follow  endocarditis,  and  in  some  instances 
they  are  apparently  induced  by  simple  irritability  of  the  heart.  They 
accompany  the  first  sound  of  the  heart,  and  are  loudest  at  the  apex. 
These  murmurs  seem  to  be  caused  by  roughening  of  the  endocardium  or 
of  the  chorda?  tendineee,  or  by  irregular  contraction  of  the  muscular  fibres 
of  the  ventricles.  They  are  of  comparatively  rare  occurrence,  and  then 
are  usually  mistaken  for  valvular  murmurs.  They  may  be  distinguished 
from  the  latter  by  their  rhythm  and  by  their  seat.  These  murmurs  are 
most  likely  to  be  confounded  with  mitral  regurgitant  and  aortic  or 
pulmonary  obstructive  murmurs. 

A  ventricular  murmur,  though  heard  at  the  apex  with  the  first  sound 
of  the  heart,  is  never  transmittal  to  the  left ;  whereby  it  is  distinguished 
from  the  mitral  regurgitant  murmur,  which  possesses  the  same  rhythm. 
A  ventricular  murmur  is  never  heard  above  the  base  of  the  heart,  and  thus 
is.  distinguished  from  aortic  and  pulmonary  murmurs. 

Frequently  in  examination  of  the  heart,  impure  sounds  are  ob- 
tained, which  closely  resemble  faint  valvular  murmurs.  They  are  gen- 
erally heard  just  at  the  end  of  inspiration,  and  usually  cease  when  respi- 
ration is  suspended.  These  are  not  constant,  but  may  come  and  go 
during  the  examination. 

Congenital  murmurs  arise  from  imperfect  closure  of  the  foramen 
ovale,  which  allows  the  blood  to  pass  directly  from  the  right  into  the  left 
auricle.  This  occasions  a  murmur  which  is  audible  over  the  base  of 
the  heart.  It  is  heard  with  the  systole  of  the  ventricles,  and  is  not 
transmitted  into  the  arteries,  or  to  the  left  of  the  apex.  It  may  thus  be 
distinguished  from  aortic  and  mitral  murmurs.  This  murmur  always 
occurs  in  early  life,  and  is  associated  with  a  cyanotic  appearance  of  the 
countenance.  "When  the  child  reaches  the  age  of  ten  or  twelve  years, 
other  endocardial  murmurs  usually  supervene. 

Hepatic  murmurs  form  another  variety  of  adventitious  sounds  due  to 
changes  in  the  composition  of  the  blood  instead  of  to  anatomical  changes 
in  the  heart.  They  are  also  termed  anaemic,  or  inorganic  murmurs. 
They  are  always  systolic,  generally  most  distinct  over  the  aorta,  and  are 
diffused  through  the  vessels  of  the  neck.  Sometimes  they  may  be  heard 
in  the  second  intercostal  space  of  the  left  side,  about  an  inch  and  a  half 
to  the  left  of  the  pulmonary  artery. 

The  hsemic  murmurs  which  are  produced  in  the  aorta  are  due  simply 
to  change  in  the  composition  of  the  blood.     Those  heard  to  the  left  of 


ANOMALOUS  HEART  SOUNDS.  205 

the  pulmonary  artery  seem  to  be  produced  by  slight  dilatation  of  the 
left  ventricle,  with  consequent  imperfect  closure  of  the  mitral  valve, 
and  more  or  less  regurgitation  of  blood  into  the  auricle. 

These  murmurs  are  inconstant;  they  often  come  and  go  during  the 
examination,  and  finally  they  permanently  disappear  as  proper  treatment 
removes  the  anaemic  condition  of  the  blood. 

The  following  characteristics  distinguish  them  from  organic  mur- 
murs: they  always  accompany  the  first  sound  of  the  heart;  they  are  soft 
and  blowing  in  character ;  those  which  are  arterial  may  be  heard  over 
many  of  the  aortic  branches  and  are  often  loudest  over  the  carotids  in- 
stead of  over  the  aorta,  where  the  aortic  obstructive  murmurs  would  be 
most  distinct.  Those  which  are  mitral  may  be  heard  a  variable  distance 
to  the  left  of  the  pulmonary  artery.  They  are  inconstant  and  likely  to 
be  present  when  the  heart's  action  is  rapid,  but  absent  when  it  is  slow. 
They  are  incapable  of  supplanting  the  normal  heart  sounds,  or  even  of 
making  them  less  distinct,  and  are  usually  associated  with  the  venous 
hum. 

These  murmurs  are  also  attended  by  the  symptoms  and  signs  of  gen- 
eral anaemia.  Except  in  complicated  cases,  they  are  not  associated  with 
the  signs  of  other  cardiac  disease. 

ANOMALOUS   HEART   SOUNDS. 

In  rare  instances,  sounds  may  be  heard  over  the  precordial  space, 
which  are  not  endocardial  or  pericardial.  These  result  from  the  action 
of  the  heart  upon  the  lungs,  and  usually  cease  when  the  respirations  are 
suspended. 

With  the  systole  of  the  ventricles,  a  loud  blowing  sound  may  be  oc- 
casioned by  a  large  pulmonary  cavity  situated  near  the  heart.  More  or 
less  distinct  blowing  sounds  are  frequently  heard  when  the  systole  of  the 
heart  occurs  just  at  the  end  of  inspiration.  These  cease  when  the  pa- 
tient holds  his  breath. 

Friction  sounds  may  be  produced  by  the  action  of  the  heart  upon 
the  overlying  pleura.  Generally  these  may  be  easily  distinguished  from 
pericardial  friction  sounds  by  their  seat,  and  by  their  disappearance  with 
the  cessation  of  respiration.  The  pericardial  friction  sounds  are  heard 
most  distinctly  along  the  left  border  of  the  sternum:  but  sounds  pro- 
duced within  the  pleura  by  the  action  of  the  heart  are  heard  most  clearly 
over  the  outer  portion  of  the  mammary  region.  They  are  also  usually 
associated  with  friction  sounds  over  other  portions  of  the  left  lung. 
Ordinary  pleuritic  friction  sounds  are  sometimes  observed  in  the  prae- 
cordial  region;  but  these  disappear  when  the  patient  holds  his  breath. 

The  sounds  caused  by  the  action  of  the  heart  upon  the  lungs  occa- 
sionally resemble  bronchial  rales ;  but  as  these  are  limited  to  the  prae- 
cordial  space,  they  are  not  likely  to  be  mistaken  for  sounds  due  to  pul- 
monarv  disease. 


206  THE  HEART. 

SUBCLAVIAN    MURMURS. 

Subclavian  murmurs  are  often  heard  just  beneath  the  clavicle,  at  the 
outer  portion  of  the  infra-clavicular  region,  more  frequently  upon  the 
left  than  upon  the  right  side.  Most  of  these  seem  to  me  to  be  produced 
by  the  pressure  of  the  stethoscope;  but  murmurs  frequently  occur  in 
this  locality,  and  over  other  parts  of  the  subclavian  artery,  which  are 
not  due  to  external  causes.  They  are  supposed  to  result  from  pressure 
upon  the  artery,  either  by  consolidated  lung  tissue  or  by  cicatricial 
bands  resulting  from  pleurisy;  but  their  exact  cause  is  not  known. 
They  are  most  frequently  associated  with  consolidation  of  the  apex  of 
the  lung. 

VENOUS   SIGNS. 

Turgescence  of  the  superficial  veins  of  the  neck  and  upper  part  of 
the  trunk  is  a  sign  of  cardiac  or  pulmonary  disease,  and  of  aortic  aneu- 
rism or  other  infra-thoracic  tumors.  The  condition  is  caused  by  direct 
pressure  on  the  veins,  or  by  increase  in  the  intra-thoracic  pressure  from 
pulmonary  disease,  and  consequent  interference  with  the  return  of  blood 
to  the  heart.  It  is  always  most  noticeable  when  the  patient  is  in  the 
recumbent  position. 

This  turgescence  may  be  either  temporary  or  permanent.  If  the 
former,  it  is  most  marked  in  expiration  or  after  attacks  of  coughing, 
and  it  will  entirely  disappear  upon  deep  inspiration. 

Temporary  t  urge 'see nee  of  these  veins  is  generally  due  to  congestion  of 
the  pulmonary  circuit,  resulting  from  disease  of  the  lungs,  which  com- 
presses the  capillaries,  and  consequently  causes  distention  of  the  pul- 
monary arteries  and  of  the  right  side  of  the  heart,  and,  through  it,  of 
the  descending  vena  cava  and  its  branches. 

Permanent  turgescence  most  commonly  results  from  disease  of  the 
mitral  valves,  which  either  obstructs  the  onward  current  of  blood  into 
the  left  ventricle  or  allows  free  regurgitation  into  the  auricle.  This 
gives  rise  to  engorgement  of  the  pulmonary  circuit,  which  cannot  be 
relieved  by  deep  inspiration.  Permanent  congestion  may  be  due  to 
obstruction  of  the  descending  vena  cava  by  a  thrombus,  or  more  fre- 
quently by  the  pressure  of  an  aneurism  or  other  tumor. 

Localized  turgescence,  confined  to  a  single  vein  and  its  branches, 
is  always  the  result  of  a  thrombus,  an  embolus,  or  of  pressure  upon  the 
blood-vessel. 

Venous  pulsation  with  marked  pulsation  in  the  jugular  veins  is 
observed  when  there  is  permanent  engorgement  of  the  descending  vena 
cava,  which  generally  results  from  extreme  emphysema  or  stenosis  of 
the  mitral  valves  with  secondary  tricuspid  regurgitation. 

Pulsation   in  the  jugular  veins  is  usually  observed  just  above  the 


VENOUS  SIGNS.  207 

clavicles,  though  sometimes  it  extends  over  the  whole  course  of  the  ves- 
sel. It  is  most  marked  in  the  dorsal  decubitus,  and  is  more  distinct 
upon  the  right  than  upon  the  left  side,  because  the  current  of  blood 
from  the  right  ventricle,  through  the  auricle,  finds  its  way  more  readily 
into  the  veins  of  that  side. 

Venous  pulsation  may  precede  the  impulse  of  the  apex  and  the  first 
sound  of  the  heart,  or  may  follow  it.  In  other  words,  it  may  be  either 
presystolic  or  systolic. 

Presystolic  venous  ■pulsation  is  due  to  regurgitation  of  blood  into  the 
veins  during  the  contraction  of  the  auricles. 

Systolic  venous  pulsation  is  due  to  contraction  of  the  right  ventricle 
with  regurgitation  of  blood  through  the  tricuspid  valves  into  the  auricle 
and  thence  into  the  veins.  When  slight  and  temporary,  this  is  termed 
relative  venous  pulsation;  when  permanent,  it  is  known  as  absolute 
venous  pulsation.  In  order  to  be  of  value  in  the  diagnosis  of  tricuspid 
regurgitation,  it  must  be  visible  during  both  inspiration  and  expiration. 

Pulsation  of  the  jugular  veins  may  be  simply  the  transmitted  impulse 
from  the  carotids.  In  such  cases,  there  will  be  simply  a  lifting  impulse, 
instead  of  expansion  of  the  blood-vessel,  and  the  vein  will  not  be  tortuous 
as  in  true  venous  pulsation. 

Pulsation  in  the  veins  on  the  back  of  the  hands  has  been  repeatedly 
noticed  by  Peter,  of  Paris,  in  advanced  consumption,  and  occasionally 
in  other  affections.  It  is  increased  by  compressing  the  wrist,  and  there- 
fore must  be  propagated  through  the  capillaries  from  the  left  side  of  the 
heart.     It  may  be  more  readily  seen  than  felt. 

Peter  thinks  this  phenomenon  due  to  paralysis  of  the  muscular  fibres 
of  the  arteries,  through  excess  of  carbonic  acid  in  the  blood.  This  rare 
phenomenon,  when  seen,  indicates  the  near  approach  of  death. 

Collapse  of  the  jtjgulab  veixs  is  said  to  occur  with  the  systole 
of  the  ventricles,  in  some  cases,  where  there  is  agglutination  of  the  two 
surfaces  of  the  pericardium. 

The  vexous  mtjemur,  venous  hum  or  bruit  tie  tliable  is  a  con- 
stant humming  sound  frequently  obtained  over  the  jugular  vein  just 
above  the  clavicle,  or  in  the  inter-clavicular  notch.  It  is  generally  asso- 
ciated with  an  arterial  ha?niie  murmur.  It  occasionally  occurs  in  healthy 
persons,  but  is  most  often  found  in  those  who  are  anasmic,  especially  in 
chlorotic  women. 

This  sign  is  most  apt  to  be  heard  when  the  patient  is  sitting  or 
standing,  and  is  usually  soft  and  humming  in  character,  but  occasionally 
musical,  hissing,  or  even  loud  and  roaring 

Intermittent  venous  murmurs  synchronous  with  the  pulsations  of  the 
heart,  are  among  the  rarest  signs  of  cardiac  disease.  They  may  be  pre- 
systolic, systolic,  or  diastolic.  The  presystolic  murmurs  are  heard  only 
when  the  patient  is  lying  down,  and  must  result  from  regurgitation  of 
blood  from  the  right  auricle  into  the  open  veins.     The  systolic  murmur 


208 


THE  HEART. 


is  usually  heard  most  distinctly  just  above  the  clavicle  on  the  right  side. 
It  is  due  to  regurgitation  from  the  right  ventricle  through  the  auricle 
and  into  the  veins.  The  diastolic  murmur  is  extremely  rare.  It  is  said 
to  require,  for  its  production,  hypertrophy  and  dilatation  of  the  heart, 
with  aneurism.  These  murmurs  may  be  mistaken  for  arterial  murmurs. 
Thev  may  be  distinguished  from  the  latter  by  slightly  pressing  on  the 
blood-vessel,  which  will  prevent  the  venous  hum,  but  will  not  so  affect 
the  arterial  murmur. 


THE   SPHYGMOGrRAPH. 


By  the  use  of  the  sphygmograph  we  are  enabled  to  obtain  a  graphic 
statement  of  the  condition  of  the  circulatory  system,  written,  as  it  were, 


Fig.  30. — Marey's  Sphygmograph. 


by  the  heart  itself.  When  all  the  conditions  are  favorable,  this  state- 
ment furnishes  interesting  information  to  physiologists;  but  so  much 
depends  upon  the  adjustment  of  the  instrument,  its  proper  working, 


■ 


Fig.  37.— Normal  Radial  Pdlsk  (Foster) 

and  the  pressure  made  upon  the  artery  that  up  to  the  present  time  the 
instrument  has  been  of  little  clinical  value.  When  all  the  conditions 
are  perfect,  the  tracings  of  the  pulse  may  indicate:   the  time  occupied 

by  the  systole  and  the  diastole  of  the  heart; 
the  force  of  the  heart's  contraction;  the  resist- 
ance to  the  onward  current  of  blood,  or  its  re- 
gurgitation through  the  valves,  and  the  tension 
of  the  arteries. 

Thetracing  is  composed  of  a  series  of  curve-, 
each  of  which  represents  a  cardiac  pulsation. 

In  the  tracing  of  the  normal  radial  pulse  as 
shown  (Figs.  37  and  38)  each  completed  series 
consists  of  a  line  of  ascent,  a  summit,  and 
a  line  of  descent.  The  line  of  ascent  a  b 
in  the  normal  condition  is  perpendicular  to 
the  plane  of  the  base.  It  is  produced  as  the  blood  is  propelled  into 
the   artery,  and  indicates   the    force    ol    the  heart    by  its  height,  and 


Fig.  3*.— Normal  Radial  Pulse 
Single  Trace  Fxlarged. 


THE  8PHYGM0GRAPH. 


209 


the  rapidity  of  the  current  of  blood,  by  its  direction.     When  the  blood 
is  retarded  in  its  passage  from  the  left  ventricle  into  the  aorta,  as  in 


Fig.  39.— Aortic  Obstruction  (Hayden). 

constriction  at  the  aortic  orifice,  this  line  will  run  more  or  less  obliquely 
to  the  right,  according  to  the  amount  of  obstruction  (Figs.  39  and  40). 


Fig.  40. — Aortic  Obstruction  (Foster). 

When  the  pulsation  is  forcible,  the  altitude  is  much  greater  than  when 
it  is  weak.     The  summit  b  (Fig.  37)  in  the  normal  condition  a  mere 


Fig.  41.— Mitral  Regurgitation. 


point,  is  reached  at  the  instant  when  the  artery  is  most  fully  distended, 
immediately  after  the  systole  of  the  left  ventricle.     When  the  vessel  is 


Left  Arm. 
Fig.  42.— Aneurism  op  Ascending  Aorta  (Loomis). 

incompletely  filled  the  summit  is  rounded,  or  the  line  of  descent  may 
run  almost  horizontally  for  a  short  distance.     Examples   of  this  are 


Fig.  43.— Aortic  Regurgitation  (Boileau). 


found  in  mitral  regurgitation  (Fig.  41),  or  when  the  artery  is  partially 
occluded  by  an  aneurism  (Fig.  42),  and  when  free  regurgitation  through 


Fig.  44.— Aortic  Obstruction  and  Regurgitation  (Loomis). 


the  aortic  valves  prevents  full  distention  of  the  artery  (Figs.  43  and  44). 
The  line  of  descent  b  c  (Fig.  37)  corresponds  to  the  period  of  arterial 
14 


210  THE  HEART. 

systole  and  cardiac  diastole.  The  length  of  the  line  indicates  the  rapid- 
ity of  the  heart's  action.  When  the  heart  is  beating  rapidly,  the  line  is 
short;  when  beating  slowly,  the  line  is  correspondingly  lengthened.  The 
undulations  in  this  line  d  ef(Fig.  37)  are  known  as  the  first,  second, 
and  third  secondary  waves.  The  first  secondary  wuve  d  is  produced  by 
the  natural  contraction  of  the  artery.  The  second  wave  e  corresponds 
to  the  impulse  occasionally  felt,  which  is  termed  dicrotism.     The  third 


Fio.  45. — Incipient  Hypertrophy  from  Obstruction  in  the  Arterioles,  due  to  Bright's 

Disease  of  the  Kidneys. 

wave  /  is  not  often  present.  The  depression  <j  marks  the  complete 
closure  of  the  aortic  valves.  A  small  notch  in  the  line  of  descent  is 
often  seen  near  the  summit. 

Instead  of  having  the  form  shown  in  this  figure,  the  line  of  descent 
may  run  obliquely  downward  in  nearly  a  straight  course.  It  may  have 
a  generally  convex  or  concave  form,  and  the  position  of  the  secondary 
waves  may  vary  in  distance  from  the  points  b  and  c. 

Convexity  of  the  line  of  descent  or  small  secondary  waves  (Fig.  45) 


Fig.  40.— Senile  Pulse  (Foster). 

are  due  to  increased  arterial  tension,  as  when  there  is  incipient  hyper- 
trophy of  the  heart  in  consequence  of  contraction  of  the  arterioles  in 
Bright's  disease. 

Concavity  of  the  line  of  descent  is  due  to  diminished  arterial  tension. 

Sudden  dropping  of  the  line  of  descent  indicates  aortic  regurgitation 
(Fig.  43). 

In  the  normal  tracing,  the  first  secondary  wave  is  found  on  a  level 


Fig.  4".— Mitral  Constriction  (Hayden). 

with  the  junction  of  the  middle  with  the  upper  third  of  the  line  of 
ascent;  but  with  loss  of  elasticity  of  the  artery  it  occurs  nearer  the  sum- 
mit, as  in  the  senile  pulse  (Fig.  46).  The  same  condition  of  the  artery 
is  indicated  by  absence  of  dicrotism. 

In  mitral  stenosis  or  constriction,  the  line  of  ascent  is  oblique,  the 
summit  rounded,  the  line  of  descent  prolonged,  and  the  secondary  waves 
are  absent  or  indistinct. 


THE  8PHYGM0GRAPH.  211 

From  what  has  been  said,  we  learn  that  the  sphygmographic  tracing 
is  not  diagnostic  of  any  disease,  as  will  be  at  once  apparent  in  looking 
over  the  tracings  taken  in  different  cases  of  the  same  disease  (Figs.  39 
and  40,  43  and  44) ;  but  the  general  appearance  of  the  curve  may  indi- 
cate special  conditions.     The  special  points  to  notice  in  the  tracing  are: 


Fig.  48. — Mitral  Constriction  and  Tricuspid  Regurgitation  (Hatden). 

the  height  and  the  obliquity  of  the  line  of  ascent;  the  acuteness  or 
rotundity  of  the  summit;  the  length  of  the  line  of  descent;  the  con- 
vexity of  the  line  of  descent;  and  the  nearness  to  the  summit  of  the 
secondary  waves. 

Sanderson  considered  this  instrument  principally  useful  in  detecting 


Fig.  49.— Hypertrophy  and  Dilatation  op  the  Heart   (Hayden).    High  line  of  ascent;  sudden 

falling  of  line  of  descent. 

increased  arterial  tension  consequent  upon  hypertrophy  of  the  left  ven- 
tricle (Fig.  45). 

Francis  E.  Anstie  thought  that  when  the  instrument  worked  per- 
fectly, if  accurately  adjusted,  it  would  be  of  value  in  the  diagnosis,  not 
only  of  commencing  hypertrophy  of  the  heart,  but  also  of  aortic  regurgi- 
tation (Fig.  43),  and  especially  of  aneurism  of  the  aorta  (Fig.  44). 


CHAPTER  XIII. 

CARDIAC  AXD   ARTERIAL  DISEASES. 
PERICARDITIS. 

Pericarditis  is  an  inflammation  of  the  pericardium,  acute,  subacute, 
or  chronic,  usually  associated  with  myocarditis  or  endocarditis  or  both. 

Anatomical  and  Pathological  Characteristics. — Acute  peri- 
carditis, like  inflammation  of  the  pleura,  is  characterized  by  dryness 
and  reddening  from  hyperemia  of  the  subserous  vessels,and  by  infiltration 
and  swelling  of  the  serous  and  subserous  tissues.  This  is  followed  by 
desquamation  of  the  endothelium,  loss  of  the  normal  glistening  charac- 
ter, and  tbe  appearance  of  a  highly  albuminous  exudate  upon  the  surface 
of  the  membrane  (pericarditis  fibrinosa).  This  is  usually  localized  at 
first,  but  becomes  more  widely  sjiread  by  the  cardiac  motion,  and  later 
assumes  a  roughened,  shaggy  aspect  (hairy  heart).  The  inflammatory 
lymph  may  cover  the  entire  surface  of  the  pericardium,  but  is  apt  to  be 
confined  to  the  upper  part. 

In  the  acute  form  of  the  disease,  serum  is  usually  effused  in  small 
amount.  It  sometimes  becomes  enclosed  in  pockets  formed  by  adhe- 
sions, but  is  sooner  or  later  absorbed.  The  opposite  walls  may  become 
permanently  adherent  by  organization  of  the  exudate  into  fibrous  bands 
which  connect  the  two  surfaces,  or  the  cavity  may  be  obliterated  by 
complete  adhesion  of  the  two  surfaces.  The  pericardium  itself  is  more 
or  less  thickened.  In  subacute  inflammation,  the  effusion  of  serum  be- 
comes abundant  (pericarditis  serosa),  its  appearance  and  quality  vary- 
ing with  the  amount  of  serum,  fibrin,  red  and  white  corpuscles  present. 
The  pericardial  sac,  when  greatly  distended,  assumes  a  pyramidal  form,  its 
base  downward,  its  apex  at  the  base  of  the  heart,  and  in  enlarging  it  en- 
croaches upon  the  lungs  and  diaphragm. 

Milk  Spots. — Frequently  opaque,  yellowish  or  gray  raised  and  sharply 
defined  patches  termed  milk  spots  are  found  on  the  surface  of  the 
pericardium,  otherwise  normal.  They  are  due  to  hyperplasia  and  in- 
creased density  of  its  fibrous  elements,  and  probably  arise  from  friction 
of  an  enlarged  heart  against  neighboring  parts  (Hamilton,  Text-Book 
of  Pathology,  page  558).  Extravasation  of  blood  into  the  sac,  with  the 
fibrin  and  serum,  characterizes  the  hemorrhagic  variety  of  pericarditis, 
commonly  associated  with  cancer  scorbutus  or  purpura. 

In  the  purulent  form,  or  pericarditis  purosa,  bacteria  are  found  in 
the  yellow  or  greenish  fluid  which  may  have  been  purulent  from  the 
first  or  have  become  so  secondarily. 


PERICARDITIS.  213 

Chronic  pericarditis  is  usually  consecutive  to  the  acute  form,  and 
often  presents,  in  addition  to  the  adhesion  and  fibrous  bands,  extensive 
thickening  and  calcareous  deposits.  Extension  of  the  inflammation  may 
result  in  myocarditis  with  weakening,  atrophy  or  fatty  degeneration  of 
the  heart  muscle,  followed  by  dilatation  of  the  cavities.  The  walls 
may  undergo  compensatory  hypertrophy;  extreme  dilatation  of  limited 
portions  of  the  ventricular  wall  constitutes  what  is  termed  cardiac 
aneurism. 

Etiology. — Acute  rheumatism  is  the  most  common  cause  of  peri- 
carditis, as  of  endocarditis  and  myocarditis,  hence  their  frequent  coex- 
istence. 

Other  not  infrequent  antecedent  disorders  are  Bright's  disease,  alco- 
holism, syphilis,  tuberculosis,  typhoid  fever,  and  acute  infectious  dis- 
ease; also  cancer,  purpura,  pernicious  anaemia,  and  scorbutus,  which 
produce  the  hemorrhagic  form.  In  early  life  the  exanthemata  often 
cause  this  affection.  It  may  also  arise  from  penetrating  wounds,  severe 
contusions,  and  by  extension  of  inflammation  from  neighboring  parts; 
occasionally  no  cause  can  be  detected. 

Symptomatology. — The  affection  may  be  divided  into  three  stages 
similar  to  those  of  pleurisy — a  dry  stage,  a  stage  of  effusion,  and  a  stage 
of  absorption. 

The  most  common  symptoms  are :  pain  in  the  precordial  and  epigas- 
tric regions,  shooting  to  the  shoulder,  and  augmented  by  movements 
or  by  pressure ;  more  or  less  fever,  the  temperature  rising  from  one  to 
four  degrees;  but  in  fatal  cases  sometimes  falling  again  shortly  before 
death;  a  small,  wiry,  irregular  pulse,  running  from  90  to  120  beats  per 
minute;  oedema,  dyspnoea,  and  occasionally  dysphagia.  Any  or  all  of 
these  symptoms  may  be  absent;  usually  there  is  a  history  of  coincident 
or  preceding  rheumatism. 

The  essential  signs  in  the  order  of  their  occurrence  are:  irritable 
action  of  the  heart;  friction  fremitus  and  murmur;  increased  cardiac 
dulness,  ultimately  obtained  over  a  triangular  area  extending  consid- 
erably to  the  left  of  the  apex;  feebleness  of  the  heart's  impulse  and 
sounds,  both  of  which  are  intensified  when  the  patient  leans  well  for- 
ward. 

In  the  first  stage,  upon  inspection  and  palpation,  we  discover  nothing 
except  an  irritable  action  of  the  heart,  with  slightly  increased  force,  and, 
in  the  latter  part  of  the  first  stage,  friction  fremitus. 

Upon  auscultation,  a  grazing  friction  sound  may  sometimes  be  heard 
very  early  in  the  disease  along  the  left  border  of  the  sternum,  usually 
most  distinct  at  the  fourth  costo-sternal  junction.  This  sound  may  be 
distinguished  from  endocardial  murmurs  by  its  rhythm  and  seat,  and  by 
the  fact  that  its  intensity  is  increased  by  pressure  and  by  a  full  inspira- 
tion. In  the  latter  part  of  this  stage,  friction  sounds  of  a  harsher  qual- 
ity may  be  obtained.     These  may  be  either  feeble  or  very  intense. 


214  CARDIAC  AND  ARTERIAL  DISEASES. 

In  the  second  stage  of  the  disease,  the  signs  vary  somewhat  with  the 
amount  of  effusion. 

On  inspection  in  children  and  young  adults,  with  elastic  chest  walls, 
bulging  of  the  precordial  region,  extending  from  the  second  to  the  sixth 
rib,  may  be  noticed.  The  respiratory  movements  of  the  left  lung  are 
somewhat  impeded,  and  the  apex  beat  is  carried  upward  and  to  the 
left  into  the  fourth  intercostal  space. 

Palpation  confirms  the  signs  obtained  by  inspection.  The  impulse 
of  the  heart  is  feeble,  especially  when  the  patient  is  lying  upon  his  back; 
but  when  he  is  leaning  forward,  it  is  much  more  forcible  than  in  either 
the  erect  or  the  recumbent  position.  This  is  an  important  fact  in  the 
diagnosis.  When  the  pericardium  is  greatly  distended,  the  diaphragm 
may  be  forced  downward,  so  as  to  cause  bulging  in  the  epigastric  region. 
Undulation  of  the  whole  precordial  region,  due  to  the  action  of  the 
heart  upon  the  surrounding  fluid,  may  frequently  be  felt,  and  occasion- 
ally fluctuation  can  be  detected. 

Upon  percussion,  both  the  superficial  and  the  deep-seated  areas  of 
dulness  are  increased.  At  first  the  latter  is  increased  in  its  vertical 
diameter,  and  dulness  is  noticeable  principally  above  the  base  of  the 
heart  in  the  second  intercostal  space,  where  the  serum  first  collects. 
This  is  especially  marked  when  the  person  is  in  the  recumbent  posture. 

Von  Stotl'ella,  of  Vienna,  has  noticed  in  these  cases  a  dulness  over  the  base  of 
the  heart  in  recumbency  change  to  resonance  when  the  patient  sits  up  (Interna- 
tionale klinische  Rundschau,  Feb.,  1890). 

When  the  effusion  becomes  somewhat  greater,  serum  collects  at  the 
lower  part  of  the  pericardial  sac;  dulness  is  then  increased  in  the  trans- 
verse diameter  at  the  level  of  the  apex,  and  the  area  of  dulness  becomes 
triangular  with  its  base  downward,  corresponding  to  the  form  of  the 
pericardium.  This  triangular  shape  remains,  however  great  the  effu- 
sion may  be.  In  extensive  effusion,  the  dulness  may  extend  from  the 
first  rib  above  to  the  resonance  of  the  stomach  below,  and  laterally  from 
the  right  nipple  to  a  point  about  two  inches  beyond  the  left  nipple. 

E.  Pins,  in  well-marked  cases,  has  frequently  observed,  when  the  patient  is 
recumbent  or  sitting-,  a  small  area  on  the  left  side  posteriorly,  over  which  there 
is  dulness  with  bronchial  breathing  and  increased  vocal  resonance,  but  no  rales 
or  friction  sounds  (Wiener  medizinische  Presse,  March,  1890). 

This  is  most  marked  in  a  circular  space  the  size  of  a  silver  dollar,  extending 
from  a  point  aboutthree  fingers'  breadth  below  the  angle  of  the  scapula  to  within 
two  of  the  lower  margin  of  the  lung.  If  the  patient  bends  forward,  and  especially 
if  he  assumes  the  knee-elbow  posture,  dulness  largely  disappears,  vesicular  reso- 
nance taking  the  place  of  abnormal  sounds.  These  phenomena  are  probably  due 
to  pressure  upon  the  lung,  which  is  relieved  by  a  forward  displacement  incident 
to  change  in  posture. 

The  position  of  the  apex  beat  having  been  determined  by  palpation 
or  auscultation,  the  existence  of  dulness  to  the  left  of  this  point  and 


PERICARDITIS.  215 

below  it  becomes  an  important  element  in  distinguishing  pericarditis 
from  enlargement  of  the  heart;  in  the  latter  the  apex  beat  corresponds 
very  nearly  to  the  limit  of  dulness  on  the  left. 

In  the  differential  diagnosis  of  pericardial  effusions,  T.  M.  Rotch,  of  Boston, 
considers  an  area  of  flatness  in  the  fifth  intercostal  space  of  the  right  side,  about 
an  inch  from  the  border  of  the  sternum,  a  very  important  sign. 

The  friction  sounds  usually  heard  on  auscultation  in  the  first  stage 
generally  disappear  when  effusion  occurs,  in  consequence  of  the  separa- 
tion of  the  pericardial  surfaces;  yet  they  may  remain  at  the  base  of  the 
heart  throughout  the  disease.  In  the  second  stage,  the  heart  sounds 
are  feeble  and  distant,  but  may  be  rendered  more'  distinct  by  causing 
the  patient  to  lean  well  forward ;  sometimes  friction  sounds  may  be 
reproduced  by  this  means. 

Pulmonary  sounds  are  not  heard  over  the  area  of  flatness  in  the 
prsecordial  region. 

In  the  third  stage,  the  signs  of  the  second  stage  disappear,  the  bulging 
gradually  diminishes,  the  apex  beat  becomes  more  and  more  perceptible 
and  returns  to  its  normal  position;  there  is  a  gradual  diminution  in  the 
area  of  dulness;  friction  sounds  may  return  and  remain  until  resolution 
has  taken  place,  or  until  the  two  surfaces  of  the  pericardium  have  be- 
come adherent;  the  respiratory  sounds  may  again  be  heard  in  the  prae- 
cordia. 

Exceptional. — Occasionally  friction  sounds  continue  long  after  apparent  re- 
covery. 

We  have  no  means  of  determining  when  adhesions  of  the  pericardial 
surface  have  taken  place  unless  the  external  layer  of  the  sac  has  also 
adhered  to  the  chest  walls.  When  this  has  occurred,  the  intercostal 
spaces  are  seen  to  be  depressed  with  each  systole  of  the  ventricles,  and 
ultimately  permanent  depression  of  the  prsecordial  region  may  take 
place.  In  some  cases,  when  the  heart  is  considerably  hypertrophied  and 
dilated,  dragging  in  of  the  epigastric  region  is  caused  by  each  pulsation 
of  the  heart. 

Diagnosis. — Pericarditis  is  liable  to  be  mistaken  for  pleurisy  or  en- 
docarditis or  for  mediastinal  tumors. 

The  first  stage  oi  pleurisy  causes  pain  and  friction  sounds  similar  to 
those  of  pericarditis,  and,  if  it  happen  to  involve  only  the  anterior  por- 
tion of  the  left  pleura,  considerable  care  will  be  necessary  to  avoid  an 
error  in  diagnosis.  The  distinctive  features  between  the  two  affections 
are  presented  in  the  following  table : 

Pericarditis.  Pleurisy. 

History. 
Commonly  of  rheumatic  origin.  Non-rheumatic. 


216  CARDIAC  AND   ARTERIAL  DISEASES. 

Pericarditis.  Pleurisy. 

Symptoms. 

Pain  usually  in  the  precordial    re-  Pain   usually   in    the    infra-axillary 

gion.  region. 

Signs. 

Friction  sounds  confined  to  the  re-  Friction  sounds,  though  they  may 

gion    of    the   heart  and  s3'nchronous        be  confined  to  the  precordial  region, 

with  its  movements,  and  not  affected        are  generally  heard  farther  to  the  left. 

by  the  respiratory  movements.  They  are   not  synchronous  with   the 

pulsations  of  the  heart,  but  occur  with 
the  respiratory  movements,  and  al- 
most invariably  cease  when  respira- 
tion is  suspended. 

Symptoms  due  to  pressure  by  mediastinal  tumors  on  vessels  or  nerves 
or  bronchi  are  prominent;  not  so  in  pericarditis.  There  is  also  accom- 
panying enlargement  of  the  glands  of  the  neck,  aDd  absence  of  some  of 
the  symptoms  and  signs  of  inflammation  which  characterize  pericarditis. 
Malignant  growths  also  cause  marked  and  peculiar  cachexia  and  have  no 
history  of  rheumatism. 

For  the  distinctive  features  between  endocarditis  and  inflammation 
of  the  pericardium,  see  endocarditis. 

Prognosis. — Acute  rheumatic  pericarditis  usually  ends  in  resolution 
within  three  weeks,  very  rarely  in  death.  It  may,  however,  become  sub- 
acute or  chronic. 

Adhesive  obliteration  of  the  pericardial  sac  tends  to  weaken  the 
heart  muscles,  and,  if  associated  with  a  crippled  condition  of  the  valves, 
is  unfavorable;  usually  such  adhesions  result  in  cardiac  hypertrophy. 
Slight  adhesions  always  remain  but  are  of  little  significance. 

Fluid  effusion  is  absorbed  in  most  cases  in  ten  to  fifteen  days,  but 
large  pericardial  effusion  may  cause  sudden  death,  or  by  long-continued 
embarrassment  of  the  heart's  activity  give  rise  to  atrophy  or  fatty  de- 
generation and  consequent  danger  of  sudden  death  from  pulmonary 
oedema  or  cardiac  paralysis  on  slight  over-exertion.  Purulent  and  hem- 
orrhagic pericarditis  are  always  dangerous.  Pericarditis  accompanying 
nephritis  is  serious. 

Treatment. — With  the  first  symptoms  of  pericarditis,  the  patient 
should  be  put  to  bed,  to  remain  absolutely  quiet  until  convalescence 
has  been  established.  Hot  poultices  should  be  kept  constantly  applied 
to  the  whole  anterior  surface  of  the  Chest.  Opiates  should  be  given  in 
just  sufficient  quantity  to  control  pain.  Depressing  measures  of  all 
kinds  must  be  avoided. 

If  the  cause  of  the  disease  can  be  ascertained,  it  should  be  removed. 
Kheumatism  will  call  for  alkalies,  guaiacum,  or  small  doses  of  colchi- 
cum.  The  latter  must  not  be  given  in  doses  sufficient  to  derange  diges- 
tion or  cause  depression.     Salicylic  acid  should  not  be  given  on  account 


PERICARDITIS.  217 

of  its  depressing  effects  on  the  heart,  but  the  salicylates  are  less  objec- 
tionable. If  this  affection  follow  depressing  fevers,  the  supporting 
measures  which  are  required  for  the  latter  should  be  more  assiduously- 
applied.  If  it  result  from  Bright's  disease,  saline  cathartics  in  mod- 
erate doses,  diaphoretics,  especially  vapor  or  hot-air  baths,  dry  cupping 
over  the  loins,  and  small  doses  of  digitalis  will  be  indicated.  In  most 
cases,  iron  is  a  necessary  remedy,  and  quinine  will  usually  be  beneficial  in 
maintaining  strength. 

The  diet  should  be  concentrated  and  nutritious,  and,  so  far  as  possi- 
ble, fluids  should  be  avoided.  If  effusion  takes  place,  its  removal  will 
be  favored  more  by  the  means  calculated  to  maintain  the  strength  than 
by  the  various  drastic  cathartics  so  often  prescribed.  In  many  cases, 
good  effects  will  follow  the  judicious  use  of  hot-air  baths,  to  promote 
diaphoresis;  or  of  potassium  iodide,  bitartrate,  or  acetate,  or  fluid  extract 
of  scoparius,  to  cause  diuresis;  or  of  fluid  extract  of  euonymus  or  small 
doses  of  elaterium,  to  induce  catharsis. 

If  pressure  on  the  heart  from  pericardial  effusion  becomes  excessive, 
the  question  of  aspiration  will  suggest  itself.  I  would  recommend  this 
operation  in  cases  where  heart  failure  seems  imminent,  but  it  should  be 
held  as  a  last  resort. 

During  convalescence  from  this  disease,  the  greatest  care  is  necessary 
for  ten  or  twelve  weeks  to  avoid  exposure  or  active  exercise.  The  heart 
is  always  weakened  by  such  an  attack,  and  there  is  a  tendency  to  dilata- 
tion, which  should  be  guarded  against  by  small  doses  of  digitalis,  strych- 
nine, and  arsenious  acid.  To  promote  strength  still  further,  we  should 
make  free  use  of  iron  and  good  diet.  The  patient  should  avoid  every- 
thing which  would  cause  the  heart  extra  labor. 

If  acute  inflammation  of  the  pericardium  does  not  terminate  in  re- 
covery within  three  weeks,  the  disease  is  termed  chronic  pericarditis. 
This  condition  may  be  characterized  by  a  collection  of  fluid  in  the  peri- 
cardium or  by  adhesion  of  the  two  surfaces  of  this  sac.  If  the  fluid  be- 
comes purulent  it  is  termed  pyo-pericardium. 

In  the  former  case,  counter-irritation,  diuretics,  and  cathartics  are 
indicated;  but  in  both  cases,  iron  and  cardiac  tonics  must  be  constantly 
employed,  and  excessive  action  is  to  be  avoided.  If  the  effusion  be  puru- 
lent, or  if  a  non-purulent  accumulation  be  sufficient  to  cause  great  irregu- 
larity of  the  heart  with  muffling  of  its  sounds,  or  to  threaten  collapse, 
aspiration  should  be  performed,  preferably  in  the  fifth  intercostal  space, 
two  and  a  quarter  inches  to  the  left  of  the  meso-sternal  line,  i.e.,  near 
the  junction  of  the  sixth  costal  cartilage  with  the  rib.  Some  recom- 
mend a  point  between  the  left  side  of  the  ensiform  cartilage  and  the 
adjacent  border  of  the  costal  cartilages.  In  pyo-pericardium,  aspiration 
may  be  repeated  several  times,  but  with  small  hope  of  permanent  relief. 
Incision,  followed  by  antiseptic  irrigation  and  temporary  drainage,  has 
been  recommended. 


218  cardiac  and  arterial  diseases. 

pneumo-hydropericardium. 

Pneumo-hydropericardium  is  one  of  the  rarest  of  cardiac  diseases. 
As  the  name  indicates,  it  is  a  condition  in  which  air  or  gas  and  fluid 
occupy  the  pericardial  sac. 

Etiology. — Air  or  gas  may  enter  the  pericardial  sac  through  a  pen- 
etrating wound  or  fistulous  tract  communicating  with  the  trachea, 
bronchi,  oesophagus,  stomach,  or  possibly  the  intestines;  or  gas  may  in 
rare  instances  result  from  decomposition  of  fluid  within  the  sac  (Da 
Costa,  Medical  Diagnosis;  also  Hamilton,  Text-Book  of  Pathology). 

Symptomatology. — The  essential  signs  of  the  affection  are  tympanitic 
resonance  over  the  air,  and  flatness  over  the  fluid,  changing  as  the  patient 
shifts  from  recumbency  to  the  sitting  posture;  and,  on  auscultation,  a 
splashing  sound  synchronous  with  the  pulsation  of  the  heart  and  entirely 
independent  of  the  respiratory  movements.  The  heart  sounds  have  a 
metallic  quality.     The  symptoms  are  similar  to  those  of  pericarditis. 

Diagnosis. — Pneumo-hydrothorax  and  certain  conditions  of  the 
stomach  might  possibly  be  mistaken  for  pneumo-hydropericardium;  but 
there  is  no  danger  of  an  error  in  diagnosis  if  we  remember  that  the 
signs  of  pneumo-hydrothorax  are  found  on  the  side  and  posteriorly;  and 
that  the  splashing  sounds  sometimes  produced  within  the  stomach  are 
heard  below  the  precordial  region. 

Prognosis  and  Treatment. — The  cases  are  usually  speedily  fatal. 
When  they  are  prolonged,  the  treatment  must  be  expectant. 

HYDROPERICARDIUM. 

Hydropericardium  is  a  transudation  or  non-inflammatory  effusion 
into  the  pericardial  sac  similar  to  that  of  hydrothorax. 

Anatomical  and  Pathological  Characteristics. — The  liquid  is 
of  a  pale  yellow  or  greenish  color,  alkaline  reaction,  saltish  taste,  is  not 
spontaneously  coagulable,  and  has  a  specific  gravity  of  1005  to  1024. 

The  quantity  varies  from  a  few  ounces  to  several  pounds;  the  peri- 
cardium in  the  latter  case  being  markedly  distended  and  presenting  the 
appearance  of  an  obtuse  cone  with  base  downward. 

Long-continued  or  excessive  pressure  of  this  effusion  greatly  impedes 
cardiac  action,  and  the  heart  muscle  weakens  and  degenerates. 

Etiology. — Hydropericardium  usually  accompanies  dropsical  effu- 
sion into  the  other  closed  cavities,  dependent  upon  heart,  renal,  or  pul- 
monary disease;  rarely  it  is  due  to  an  altered  condition  of  the  blood  ac- 
companying the  cancerous  and  other  grave  cachexia;. 

Symptomatology. — The  symptoms  and  signs  are  similar  to  those 
attending  the  effusion  of  pericarditis,  but  without  friction  sounds  or 
other  symptoms  of  inflammation. 

Diagnosis. — The  diagnosis  depends  on  the  history  and  the  manifesta- 


ACUTE  ENDOCARDITIS,  219 

tions  of  the  causative  disease,  with  increased  disturbance  of  the  heart, 
enlarged  area  of  cardiac  dulness,  and  signs  peculiar  to  the  presence  of 
fluid  in  the  pericardium.  Exploratory  aspiration  may  be  employed  if 
necessary. 

Prognosis. — If  the  effusion  is  large  in  amount  and  accompanies  val- 
vular lesions,  it  may  cause  sudden  death  from  pressure  upon  an  already 
embarrassed  heart.  Treatment  should  be  chiefly  directed  to  the  causative 
disease,  from  which  death  usually  occurs. 

ACUTE   ENDOCARDITIS. 

Inflammation  of  the  lining  membrane  of  the  heart  may  be  acute  or 
chronic.  The  former  is  usually  a  non-ulcerative  affection  the  result  of 
rheumatism,  but  an  ulcerative  form  also  occurs  as  the  product  of  septic 
infection.  It  has  been  variously  termed  ulcerative,  infectious,  septic, 
and  by  A7irchow,  malignant  endocarditis.  Chronic  endocarditis  may  be 
such  from  the  beginning,  but  it  usually  follows  the  simple  acute  form 
of  the  disease. 

Anatomical  axd  Pathological  Characteristics. — Normally  the 
endocardium  from  within  outward  consists  of  a  single  layer  of  polygonal 
endothelial  cells,  a  thin  elastic  basement  membrane,  and  a  layer  of  nucle- 
ated white  fibrous  tissue  joined  to  the  cardiac  muscular  structure  by 
loose  areolar  tissue.  The  valves  of  the  heart  are  reduplications  of  the 
endocardium,  those  at  the  auriculo-ventricular  septum  containing  also 
a  few  striated  muscular  fibres.  Blood-vessels  ramify  in  the  loose  areolar 
tissue,  but  nowhere  penetrate  the  three  layers  of  the  endocardium ;  these, 
like  the  cornea,  receive  nourishment  from  the  lymphatic  spaces. 

A  few  vessels  accompany  the  muscular  fibres  of  the  mitral  and  tricuspid 
valves. 

In  the  early  stage  of  acute  endocarditis,  the  endocardium  appears 
slightly  opaque  or  distinctly  cloudy;  later  it  is  roughened,  but  redness  is 
rarely  visible  after  death.  The  sub-endocardial  capillary  plexus  is  in- 
jected. The  lymph  spaces  are  crowded  with  inflammatory  products.  The 
fibrous  layer,  chiefly,  but  also  the  areolar  tissue,  becomes  infiltrated  with 
round  cells;  as  these  proliferate,  cloudy  swelling  occurs  in  the  native 
fibrous  cells,  which  appear,  as  the  disease  advances  (Hamilton,  Text- 
Book  of  Pathology)  to  become  homogeneous  and  to  be  in  great  part 
absorbed.  The  affected  membrane  becomes  thickened;  proliferation  of 
cells  and  their  irregular  accumulation  gradually  forces  the  endothelium 
and  basement  structure  before  it,  producing  minute  papillary  projections. 
Swelling  and  consequent  distention  finally  result  in  destruction  of  the 
basement  layer,  and  endothelial  desquamation  at  the  summits  of  the 
projections;  upon  these  fibrin  is  deposited  from  the  blood  current.  As 
the  growth  thus  increases  by  proliferation  within  and  fibrinous  accretion 
without,  it  takes  an  irregular  verrucous  form,  spreading  at  its  summit 


220  CARDIAC  AND  ARTERIAL  DISEASES. 

and  constricted  at  its  base.  These  vegetations  develop  most  luxuriantly 
upon  the  valvular  margins  where  most  friction  occurs,  especially  along 
the  ventricular  margin  of  the  aortic  valve.  They  may  attain  the  size  of 
a  pea.  This  process  is  attended  by  no  vascularization  until  far  advanced, 
when  the  vessels  at  the  base  extend  for  a  short  distance  into  the  vege- 
tation (Hamilton,  loc.  cit.). 

Etiology. — Acute  endocarditis  occurs'  most  frequently  in  those 
under  thirty  years  of  age,  and  is  most  often  the  result  of  acute  rheuma- 
tism. It  also  occurs  in  those  suffering  from  gout,  diabetes,  alcoholism, 
Bright's  disease,  scarlet  fever,  typhoid  fever,  diphtheria,  pneumonia, 
syphilis,  and  tuberculosis ;  chorea  appears  to  be  an  occasional  cause. 

Symptomatology. — The  usual  symptoms  are:  a  sense  of  uneasiness 
about  the  heart,  fever,  a  short  cough,  dyspnoea,  and  an  anxious  counte- 
nance. 

The  temperature  rarely  reaches  103^°  F.  In  some  cases  vertigo  and 
other  cerebral  symptoms  may  occur,  or  gastric  disturbance,  but  none  of 
these  are  constant  features. 

Among  the  signs,  inspection  commonly  reveals  turgescence  and  an 
anxious  expression  of  the  face.  The  cardiac  impulse  may  be  visible  over 
an  enlarged  area. 

In  the  beginning,  the  pulsations  are  apt  to  be  forcible  and  irregular, 
with  a  corresponding  pulse.  An  endocardial  thrill  is  sometimes  detected 
by  palpation. 

Percussion  gives  no  increase  of  dulness  in  uncomplicated  cases. 

Auscultation  usually  reveals  a  soft,  systolic  murmur,  due  to  endo- 
cardial or  valvular  thickening  or  roughening;  these,  however,  may  be 
present  without  a  murmur.  Often  the  second  sound  at  the  base  is 
doubled  from  inco-ordinated  action  of  the  two  sides  of  the  heart.  Mur- 
murs may  occur  from  lesions  at  any  of  the  valves,  but  are  most  frequently 
heard  at  the  apex. 

Diagnosis. — When  some  of  the  above  symptoms  appear  in  the  course 
of  any  of  the  causative  diseases,  and  these  signs  are  obtained  over  a 
heart  the  sounds  of  which  were  formerly  normal,  we  may  reasonably 
suspect  inflammation  of  the  endocardium. 

Acute  endocarditis,  when  occurring  independent  of  pericarditis,  is 
liable  to  be  mistaken  for  the  latter  disease.  Pericarditis  may  be  dis- 
tinguished from  uncomplicated  inflammation  of  the  endocardium  by 
the  quality,  rhythm  and  seat  of  the  murmur. 

Acute  endocarditis.  Pericarditis. 

Quality  of  murmur. 
Murmur  blowing.  Distinctly  rubbing  or  friction  sound, 

to-and-fro  shuffling  ;  increased  in  in- 
tensity on  the  patient's  bending  for- 
ward and  taking  a  deep  inspiration, 
also  by  pressure  of  stethoscope. 


ACUTE  ENDOCARDITIS.  221 

Acute  endocarditis.  Pericarditis. 

Rhythm  of  murmur. 
Murmur  synchronous  with  the  first  Murmur    not    exactly    synchronous 

sound  of  the  heart,  and  does  not  occur        with  the  valvular  sounds,  and  often 
with  the  diastole  unless  regurgitation        occurs  during  both  the  systole  and  the 
takes  place  through  the  aortic  or  pul-        diastole  of  the  heart ;  is  not  constant. 
monary  semilunar  valves. 

Seat  of  murmur. 
Murmur  loudest  at  apex  of  heart,  and  Murmur  heard  loudest  at  border  of 

diffused  beyond  the  praecordia.  sternum  near  the  fourth  or  fifth  left 

costal    cartilage.      Limited    to     prae- 
cordia. 

Prognosis. — -Acute  rheumatic  endocarditis  usually  runs' its  course  in 
two  to  four  weeks,  and  is  seldom  fatal  unless  complicated  with  other 
disorders.  One  attack,  however,  renders  the  part  more  vulnerable  to 
subsequent  disease.  In  favorable  cases,  endocardial  murmurs  decrease 
or  entirely  disappear  during  convalescence,  but  permanent  valvular 
lesions  remain  in  about  twenty-five  per  cent  of  all  cases  of  acute  mitral 
endocarditis  (Loomis'  Practical  Medicine).  These,  especially  in  chil- 
dren, are  usually  rapidly  compensated  for  by  cardiac  hypertrophy. 
These  permanent  lesions  often  cannot  be  detected  until  contraction  of 
the  inflammatory  products  takes  place,  some  weeks  or  months  after 
subsidence  of  the  acute  inflammation. 

The  prognosis  is  rendered  correspondingly  grave  by  marked  antece- 
dent depreciation  of  general  health  ;  by  the  coexistence  of  disease  of  the 
pericardium  or  heart  muscle ;  by  an  intercurrence  of  pulmonary  and  other 
diseases ;  by  the  development  of  typhoid  symptoms ;  or  the  presence  of  signs 
and  symptoms  indicative  of  cerebral,  splenic,  hepatic,  or  renal  embolism. 

Treatment. —Endocarditis  is  nearly  always  the  result  of  rheuma- 
tism, chorea,  pyaemia,  or  the  acute  exanthematous  fevers.  The  proper 
treatment  for  these  affections  is  that  which  should  in  the  main  be  em- 
ployed in  the  secondary  heart  disease. 

Perfect  quiet  should  be  maintained,  not  only  during  the  active  stage, 
but  also  during  the  convalescence. 

In  the  very  inception  of  the  attack,  a  full  dose  of  quinine  will  occa- 
sionally cut  it  short.  Later,  this  remedy  and  iron  are  very  useful.  Dur- 
ing the  treatment,  the  patient  should  be  kept  in  a  warm  room  at  70°  to 
75°  F.,  and  the  chest  should  be  specially  guarded  from  exposure. 

Sibson  recommends  a  liniment  of  tincture  of  belladonna  and  chloro- 
form sprinkled  on  cotton-wool  and  kept  applied  to  the  precordial  region. 
Great  depression  calls  for  alcoholic  stimulants  and  nux  vomica  or  digi- 
talis. The  latter  in  moderate  doses,  combined  with  quinine,  arsenious 
acid,  and  iron,  is  needed  during  convalescence,  but  care  should  be  taken 
not  to  overstimulate  the  heart. 

Exceptional — Nearly  all  cases  of  endocarditis  are  associated  with  or  follow 


222  CARDIAC  AND  ARTERIAL  DISEASES. 

other  diseases,  and  are  attended  by  symptoms  which  demand  supporting  treat- 
ment :  but  now  and  then  one  occurs  without  apparent  cause  in  a  robust  person 
of  fall  habit.  In  such  case,  general  bleeding  would  undoubtedly  prove  benefi- 
cial by  relieving  the  over-burdened  heart. 

ULCERATIVE   ENDOCARDITIS. 

Ulcerative  endocarditis  is  a  destructive  inflammation  of  the  endocar- 
dium due  to  infection,  usually  running  a  rapid  and  fatal  course.  Either 
or  both  sides  of  the  heart  may  be  its  seat,  but  most  frequently  the  left  is 
involved.  On  the  surface  of  the  endocardium,  chiefly  on  the  valves, 
may  be  found  gray  fleshy  vegetations  springing  from  the  sub-serous 
tissue,  frequently  associated  with  greenish-colored  clots  and  containing 
perhaps  minute  purulent  cavities. 

Micro-organisms  are  always  present,  pyogenic  bacteria,  pneumococci, 
or  tubercle  bacilli  flourishing  with  others  of  a  harmless  nature.  Ulcers 
may  coexist  with  vegetations  or  they  may  mark  the  site  of  those  which 
have  disappeared;  their  edges  are  irregular  and  thickened,  and  their 
floors  purulent;  perforation  of  the  valves  is  a  common  result.  Xot  in- 
frequently these  ulcers  are  the  source  of  septic  embolism  in  distant  organs. 

Etiology. — Ulcerative  endocarditis  may  be  caused  by  various  patho- 
genic bacteria  which  gain  entrance  to  the  circulation  in  the  different 
specific  affections  mentioned  when  speaking  of  the  etiology  and  treat- 
ment of  acute  endocarditis,  but  most  often  during  pyaemia;  occasionally 
it  arises  idiopathically. 

Symptomatology. — The  affection  often  has  symptoms  and  signs 
similar  to  those  of  myocarditis. 

The  usual  symptoms  may  be  those  of  severe  enteric  fever,  the  attack 
being  often  ushered  in  by  a  chill,  followed  by  prostration,  delirium,  or 
coma.  The  temperature  usually  ranges  higher  than  normal,  from  two 
to  four  degrees  F.  The  tongue  is  often  dry  and  brown;  vomiting  and 
diarrhoea  are  common.  The  pulse  is  rapid  and  irregular,  and  sometimes 
there  are  precordial  pains  and  palpitation  of  the  heart,  with  dyspnoea 
and  occasionally  articular  pains. 

The  evidences  of  embolism  are  often  seen. 

Sometimes  no  signs  whatever  are  present,  in  other  instances  auscul- 
tation reveals  the  signs  of  valvular  disease,  and  repeated  examination 
may  show  rapidly  progressing  valvular  changes. 

Diagnosis. — The  absence  of  cardiac  symptoms  in  many  cases  is 
likely  to  mislead  the  physician  into  the  diagnosis  of  intermittent  or 
typhoid  fever,  or  of  pyaemia;  but  if  attention  is  directed  to  the  heart, 
and  it  is  known  to  have  been  previously  healthy,  the  occurrence  of  a 
svstolic  mitral  or  tricuspid  murmur,  with  the  symptoms  just  mentioned, 
renders  the  diagnosis  reasonably  certain. 

Prognosis. — The  prognosis  is  always  grave,  the  disease  usually  ter- 
minating in  death  from  the  primary  septic  condition  or  from  secondary 
pyEemic  involvement  of  the  brain,  kidneys,  spleen,  liver,  or  other  organs, 


CHRONIC  ENDOCARDITIS.  223 

evidenced  by  hemiplegia  or  albuminuria  or  sudden  enlargement  and 
tenderness  of  the  spleen  or  liver. 

Teeatment. — Ulcerative  endocarditis  results  from  pyaemia  or  septi- 
caemia, and  consequently  requires  the  most  vigorous  supporting  mea- 
sures.    Large  doses  of  quinine  and  alcoholic  stimulants  are  indicated. 

Sansom  recommends  sodium  sulpho-carbolate  in  thirty-grain  doses, 
with  inunctions  of  carbolized  oil  (London  Practitioner,  Jan.,  1889). 

CHRONIC  ENDOCARDITIS— VALVULAR  DISEASE  OF  THE  HEART. 

In  chronic  endocarditis  the  non-ulcerative  inflammation,  which  is 
less  acute  from  the  start  than  in  the  acute  disease,  becomes  protracted, 
cell  infiltration  and  hyperplasia  being  followed  by  organization  and 
marked  contraction,  especially  at  the  base  of  the  vegetation.  The 
thickened  tissues  commonly  become  atheromatous  in  patches,  these  in 
turn  undergoing  calcification,  as  seen  in  the  yellow  areas  and  nodules  of 
concretion  scattered  over  the  surface.  Frequently  it  is  coincident  with 
a  like  condition  in  the  walls  of  the  aorta.  Indolent  ulcers  sometimes 
exist  where  calcareous  scales  have  been  detached  or  where  an  atheroma- 
tous patch  has  softened.  These  changes  may  occur  on  any  part  of  the 
endocardium,  but  the  local  effects  of  chronic  endocarditis  are  most  dis- 
tinctly recorded  in  the  valves. 

Following  the  slight  thickening  of  the  acute  stage,  there  is  greater 
hyperplasia  of  the  areolar  and  white  fibrous  tissue,  especially  along  the 
edges  of  the  valves.  Organization  with  inevitable  retraction  produces 
incompetence  of  the  valves.  Narrowing  of  the  aortic  orifice  may  also 
result  from  the  occurrence  of  the  same  process  in  the  fibrous  ring  which 
normally  exists  at  the  base  of  the  valves  at  the  cardio-aortic  junction. 
Complete  calcification  of  this  ring  is  an  occasional  result. 

Atheroma  and  calcareous  deposits  also  occur  in  the  valves. 

Adhesions  may  form  between  the  valves  and  the  aortic  wall.  Vege- 
tations often  fringe  their  ventricular  margin.  Ulceration  prone  to  fol* 
low  fibrosis  and  atheroma  may  perforate  the  valve  entirely,  or  from  partial 
destruction  give  rise  to  valvular  aneurism.  The  mitral  valves  are  sub- 
ject to  similar  changes,  and,  as  the  free  edges  of  the  valves  are  continu- 
ous, general  contraction  narrows  the  orifice  in  marked  cases  to  a  mere 
slit  like  a  buttonhole. 

The  chordae  tendineaa  are  involved  in  the  process  of  thickening  and  re- 
traction, and  may  become  agglutinated  into  one  or  more  short,  fibrous 
bands  which  draw  down  the  contracted  mitral  margin,  converting  the 
valves  into  a  funnel-shaped  projection  into  the  ventricle. 

The  tricuspid  valve  is  seldom  so  affected.  Aortic  regurgitation  or 
obstruction  produces  dilatation  of  the  left  ventricle  followed  in  favora- 
ble cases  by  compensatory  hypertrophy  of  its  walls.  Like  conditions  of 
the  mitral  orifice  produce  like  effects  in  the  left  auricle. 


224  CARDIAC  AND  ARTERIAL  DISEASES. 

Theoretically,  similar  affections  at  the  tricuspid  and  pulmonary  valves 
produce  corresponding  changes  in  the  cavities  and  walls  of  the  right 
heart;  but  practically  tricuspid  stenosis,  and  stenosis  and  regurgitation 
at  the  pulmonary  valves,  are  exceedingly  rare.  Tricuspid  regurgitation, 
with  dilatation  and  hypertrophy  of  the  right  heart,  is  usually  the  result 
of  serious  lesions  of  the  left  heart. 

Chronic  valvular  lesions,  though  sometimes  occurring  alone  are  apt 
to  produce  disease  of  other  organs,  by  obstructing  the  circulation. 
In  the  lungs,  we  find  congestion,  oedema,  bronchitis,  apoplexy,  brown 
induration,  and  lobar  pneumonia.  The  kidneys  may  become  congested 
and  enlarged,  and  are  not  infrequently  the  seat  of  embolic  infarcts  or  mul- 
tiple abscesses.  The  same  is  true  of  the  spleen.  Continuous  engorgement 
may  cause  parenchymatous,  fatty,  or  atrophic  degeneration  of  the  liver, 
or  chronic  catarrh  of  the  gastro-intestinal  mucous  membrane;  and 
occasionally  embolism  or  apoplectic  extravasation  may  take  place  in  the 
brain. 

Endocarditis  may  produce  at  the  orifices  of  the  heart  either  obstruc- 
tion or  insufficiency  of  the  valves. 

Stenosis  or  stricture  may  be  the  result  of  thickening  of  the  valves 
from  the  presence  of  calcareous  deposit,  atheromatous  or  fibroid  tissue, 
or  extensive  vegetations ;  or  of  adhesions  between  the  valves,  or  of  indura- 
tion, hyperplasia,  and  contraction  of  the  margins  of  the  openings.  Earely 
it  is  a  congenital  condition. 

Incompetency  may  be  due  to  perforation,  tearing,  or  inflammatory  re< 
traction  of  the  valves  or  to  rigidity  from  calcareous  deposit;  to  rupture 
or  abnormal  shortening  or  lengthening  of  the  chorda?  tendinese,  dilata- 
tion of  the  ventricle  without  compensatory  lengthening  of  the  chorda?  and 
their  muscles;  and  to  spasm  of  the  columnae  carneae. 

Etiology. —  Chronic  endocarditis  is  more  frequent  in  men  than  in 
women.  It  usually  follows  the  acute  non-ulcerative  form  of  the  disease, 
but  may  be  chronic  from  the  beginning,  especially  when  associated  with 
chronic  alcoholism,  rheumatism,  gout,  or  old  age. 

Symptomatology. — Chronic  endocarditis  sooner  or  later  causes  ir- 
regularity in  the  action  of  the  heart,  lividity  of  the  lips,  oedema,  and 
dyspnoea  on  exertion.  Dizziness  and  vertigo  with  facial  pallor  and 
sometimes  syncope  arise  from  cerebral  anaemia;  sudden  loss  of  conscious- 
ness with  subsequent  paraplegia  may  arise  from  cerebral  embolism  or 
apoplexy.  Headache,  tinnitus  aurium  and  muscae  volitantes  are  com- 
monly due  to  cerebral  congestion. 

Often  cardiac  pains  occur,  frequently  shooting  to  the  left  shoulder 
and  down  the  arm.  Sometimes  there  is  true  angina  pectoris.  Cardiac 
dyspnoea  and  palpitation  are  common.  The  pulse  may  be  rapid,  weak, 
irregular,  intermittent,  small,  wiry,  or  full  and  compressible.  The  so- 
called  water-hammer,  collapsing,  jerking  or  piston  pulse  is  charac- 
teristic of  aortic  regurgitation.     The  pulse  in  other  valvular  lesions  is 


CHRONIC  ENDOCARDITIS.  225 

not  diagnostic,  but  indicates  the  force  of  the  heart,  the  tone  of  the  ves- 
sels, and  the  condition  of  the  circulation. 

If  the  pulmonary  circulation  be  embarrassed,  cough,  dyspnoea,  opjDres- 
sion,  and  profuse  expectoration  are  present,  especially  on  exertion.  Blood- 
stained sputum  is  common,  and  haemoptysis  not  infrequent. 

General  venous  engorgement  is  manifested  by  cyanosis,  tenderness 
and  enlargement  of  the  liver  and  spleen,  anorexia,  nausea  and  vomiting, 
and  sometimes  jaundice;  also  by  albuminuria  with  casts,  scanty  and  oc- 
casionally bloodstained  urine,  increasing  oedema  commencing  in  the 
lower  limbs,  and  effusion  into  the  serous  cavities. 

The  signs  require  careful' discrimination.  Aortic  obstruction,  com- 
monly manifesting  the  symptoms  of  cerebral  anaemia,  is  characterized  by 
a  hard,  wiry,  but  regular  pulse;  enlargement  of  the  left  heart;  a  systolic 
murmur  with  the  first  sound  usually  harsh,  loudest  at  the  right  second 
intercostal  space,  occasionally  at  the  left  or  over  the  upper  part  of  the 
sternum.  This  murmur  is  conveyed  into  the  vessels  of  the  neck,  is  heard 
behind,  and  toward  the  apex  but  with  diminished  intensity,  and  is  not 
transmitted  to  the  left  of  the  apex.  The  pulmonic  second  sound  is  feeble. 

Aortic  regurgitation  exhibits  no  peculiar  early  symptoms.  It  is  char- 
acterized by  a  full,  strong,  but  collapsing  pulse.  The  left  heart  is  enlarged ; 
the  carotids  beat  forcibly,  and  distinct  capillary  pulsation  may  sometimes 
be  seen  beneath  the  finger-nails  and  the  mucous  membrane  of  the  lips,  and 
at  the  fundus  of  the  eye.  It  causes  a  diastolic  murmur,  soft  and  blowing, 
occurring  with  or  following  the  second  sound,  which  is  most  distinct  over 
the  lower  part  of  the  sternum,  but  is  sometimes  heard  behind  and  in  the 
arteries  of  the  neck.     It  is  more  widely  diffused  than  any  other  murmur. 

Mitral  obstruction  causes  marked  pulmonary  symptoms  and  signs,  and 
is  accompanied  by  a  soft,  small  pulse  and  a  purring  thrill  most  distinct  at 
the  apex ;  by  left  auricular  enlargement,  sometimes  but  not  usually  elic- 
ited by  percussion;  and  by  the  mitral  presystolic  murmur  preceding  the 
first  sound  already  noted  as  represented  by  vocalizing  .the  symbols,  E  r  r  b 
or  V  o  o  t.  It  is  apt  to  be  of  longer  duration  than  other  murmurs.  Its 
maximum  intensity  is  about  half  an  inch  above  the  apex  beat,  it  is  louder 
when  the  patient  is  erect,  is  not  transmitted  to  the  left  of  the  apex  beat, 
is  not  heard  behind,  nor  in  the  arteries  of  the  neck. 

Mitral  regurgitation  commonly  produces  the  symptoms  of  pulmonary, 
hepatic,  and  renal  congestion,  and  is  accompanied  by  a  compressible 
and  irregular  pulse  and  enlargement  of  the  left  heart.  The  murmur 
produced  is  soft  and  blowing ;  it  is  systolic,  accompanying  or  replacing  the 
first  sound;  and  is  heard  loudest  at  the  apex.  It  is  transmitted  to  the 
left,  and  is  often  heard  behind  beside  the  sixth  and  seventh  dorsal  verte- 
brae opposite  the  mitral  area  in  front.  It  is  not  propagated  into  the 
arteries  of  the  neck.     The  pulmonic  second  sound  is  intensified. 

Tricuspid  regurgitation,  usually  secondary  to  lesions  of  the  left  heart 
or  to  pulmonary  diseases,  and  when  marked,  producing  symptoms  of  pas- 
T5 


220  CARDIAC  AND  ARTERIAL  DISEASES. 

sive  congestion  of  the  brain,  and  of  the  liver  and  other  abdominal  or- 
gans, exhibits  the  following  signs:  pulsation  of  the  jugulars,  enlargement 
of  the  right  heart,  a  comparatively  feeble  systolic  murmur  replacing  the 
first  sound,  and  loudest  in  the  tricuspid  area.  It  is  transmitted  to  the 
right  if  at  all,  is  not  heard  at  the  apex,  behind,  or  over  the  carotids,  and  is 
seldom  audible  above  the  third  rib.     The  pulmonic  second  sound  is  feeble. 

Tricuspid  obstruction  and  pulmonic  regurgitation  are  so  rare  as 
hardly  to  merit  mention.  The  former  causes  presystolic,  the  latter  a 
diastolic  murmur ;  the  former  harsh,  the  latter  soft ;  the  former  heard  most 
distinctly  over  the  lower  part  of  the  sternum,  the  latter  over  the  left 
second  intercostal  space,  but  propagated  downward.  The  second  pul- 
monic sound  would  probably  be  heard  in  tricuspid  obstruction,  but 
would  be  absent  in  pulmonic  regurgitation. 

Pulmonic  obstruction  causes  enlargement  of  the  right  heart  and  a 
systolic  murmur  with  the  first  sound,  of  maximum  intensity  at  the  left 
second  intercostal  space,  occasionally  transmitted  toward  the  left  shoul- 
der, but  never  downward  to  the  apex  nor  over  the  aorta  and  carotids. 
It  is  not  heard  over  the  lower  part  of  the  sternum  or  behind.  There 
may  be  an  attendant  bruit  de  diable  of  the  jugulars. 

Diagnosis. — The  differential  diagnosis  between  different  valvular 
lesions  must  be  made  from  the  foregoing  symptoms  and  signs.  In  case 
of  single,  or  clearly  defined  double  valvular  sounds,  little  confusion  need 
arise  in  determining  their  diastolic  or  systolic  character  if  their  rhythm 
be  referred  to  the  carotid  pulse.  This  in  most  cases  can  be  felt  on  deep, 
digital  pressure  beneath  the  angle  of  the  jaw,  just  in  front  of  the  ante- 
rior margin  of  the  sterno-cleido-mastoid.  Not  infrequently  an  accurate 
diagnosis  is  impossible  when  the  action  of  the  heart  is  rapid,  irregular, 
and  tumultuous.  In  these  cases  better  results  may  be  obtained  by  aus- 
cultation after  proper  exhibition  of  digitalis.  In  the  diagnosis  of 
chronic  endocarditis,  too  much  significance  must  not  be  attached  to  the 
presence  of  valvular  murmurs,  as  serious  disease  may  exist  without 
them.  Such  cases  are  indicated  by  the  various  symptoms  already  men- 
tioned and  by  feeble  or  intermittent  action  of  the  heart,  with  increased 
area  of  cardiac  dulness  due  to  hypertrophy  or  dilatation. 

Chronic  endocarditis  or  organic  disease  of  the  heart  may  be  confused 
with  functional  disease  of  the  heart,  pericarditis,  anaemia,  aneurism, 
fatty  degeneration,  cardiac  dilatation,  and  with  certain  congenital  de- 
formities of  the  heart.     The  differential  points  are  as  follows: 

Chronic  endocarditis.  Functional  heart  disease. 

History. 

Palpitation*  comes  on  gradually.  Palpitation    paroxysmal,  comes    ot 

suddenly,  not  constant. 
Frequently  history  of    rheumatism,  History  often  points  to  indigestion, 

gout,  or  syphilis.  hysteria,  the  nervous  diathesis  or  ex- 

cessive use  of  tobacco  or  colfee. 


CHRONIC  ENDOCARDITIS.  227 

Chronic  endocarditis.  Functional  heart  disease. 

Symptoms. 
Anxiety  not  marked  till  late  in  dis-  Anxiety,    worry     and     nervousness 

ease.  Palpitation  usually  brought  on  prominent.  Palpitation  usually  with- 
by  exertion.  Dyspnoea,  cyanosis,  or  out  exertion.  No  evidence  of  organic 
cough.  disturbance  other  than  anaemia. 

Signs. 

Enlargement  of  the  heart,  change  in  No  enlargement  of  heart.    Murmurs 

apex  beat.  Murmurs  may  be  dias-  if  present  are  inconstant,  always  systo- 
tolic;  they  may  replace  heart  sounds;  he.  Are  due  to  anamiia  and  disappear 
they  are  usually  constant.  on  treatment.     Heart  sounds  present 

though  feeble. 

Chronic  endocarditis.  Pericarditis. 

Signs. 

Usually  cardiac  enlargement.     Mur-  No   enlargement   till   second  stage. 

murs    constant    and   widely   diffused;         Murmurs   confined  to   narrow  limits; 

commonly     synchronous     with    heart        most  distinct  at  left  fourth  costo-ster- 

sounds  which  they  may  replace.  nal  articulation  ;   sometimes  increased 

on  pressure  with  stethoscope,  on  deep 
inspiration,  and  on  forward  inclination 
of  patient.  Murmurs  inconstant  and 
not  synchronous  with  valvular  sounds. 
Heart  sounds  not  supplanted. 

Chronic  endocarditis.  Anaemia. 

Patient  may  appear  robust.     Pulse  Pallor  and   lassitude.     Pulse   weak, 

may   be  full   and   strong.     Heart  en-  compressible.       Heart     normal     size. 

larged.      Murmurs    constant,     widely  Murmur  inconstant  and  often  loudest 

diffused.     No  venous  hum.  over  carotids.     Venous  hum. 

Chronic  endocarditis.  Thoracic  aneurism. 

Symptoms. 
No  marked  symptoms  at  beginning.  Marked     symptoms     significant    of 

pressure,  as,  boring  pain,  dysphagia, 
aphonia. 

Signs. 

Heart  enlarged.    Pulse  alike  on  both  Heart  of  normal  size.     Pulse  often 

sides.  No  dilating  impulse.  Murmur  different  on  two  sides.  Dilating  im- 
frequently  widely  transmitted.  pulse.    Peculiar  bruit  localized.    Never 

transmitted  toward  apex. 

The  diagnosis  of  fatty  heart  rests  chiefly  upon  the  history  of  the  case, 
the  absence  of  distinct  signs  of  organic  lesions,  and  the  occurrence  of 
Cheyne-Stokes  respiration. 

Congenital  deformities  of  the  heart  may  be  distinguished  by  the  his- 
tory, the  blueness  of  the  surface,  and  the  occurrence  of  a  systolic  mur- 
mur not  transmitted  to  the  left  of  the  apex  or  to  the  arteries  and  heard 
only  over  the  base  of  the  heart. 


228  CARDIAC  AND  ARTERIAL  DISEASES 

Prognosis. — Organic  valvular  heart  disease  is  rarely  if  ever  curable, 
but  in  duration  and  fatality  it  varies  widely  in  different  cases  according 
to  the  cause,  extent,  seat,  and  progressive  or  non-progressive  tendency 
of  the  lesion;  the  degree  and  rapidity  of  compensation;  the  presence  of 
complications;  the  age,  sex.  and  condition  of  the  patient  and  his  will- 
ingness and  capacity  to  follow  a  proper  mode  of  life  and  treatment. 

Infants  and  old  people  endure  valvular  disease  poorly.  In  older 
children  and  adults,  the  heart  tends  to  compensate  more  quickly. 
Women  are  oftener  affected  than  men,  but  they  have  a  better  chance  of 
prolonged  life  because  of  less  exposure  to  severe  strain  and  alcoholic  and 
ether  excesses  with  the  resulting  arterio-sclerosis,  and  angina  pectoris 
of  organic  origin.  Arduous  and  exposing  occupations  and  a  reckless  or 
passionate  disposition  influence  the  prognosis  unfavorably.  A  progres- 
sive trend  of  the  disease  evidenced  in  the  past  and  present  history  is 
unpropitious,  especially  when  associated  with  or  dependent  upon  renal 
disorder.  Evidence  of  dilatation  without  compensation  or  of  coexistent 
arterio-sclerosis  is  ominous.  The  gravity  increases  with  the  number  of 
lesions,  and  is  greatly  augmented  by  the  occurrence  of  diseases  which 
weaken  the  heart.  Heart  disease  dependent  upon  uncomplicated  chorea 
is  not  usually  serious.  In  any  case  prompt  relief  following  the  use  of 
heart  tonics  is  a  good  sign. 

In  aortic  stenosis,  compensatory  hypertrophy  is  usually  prompt  and 
may  be  efficient  for  years.  The  clanger  lies  in  failure  of  compensation, 
or  in  cerebral  embolism,  which  is  more  frequent  from  this  than  from 
any  other  valvular  disease.  Death  may  also  result  from  sudden  heart 
failure  or  from  pulmonary  oedema  after  secondary  mitral  insufficiency 
and  left  ventricular  dilatation. 

Aortic  regurgitation,  though  frequently  existing  for  years  and  with- 
out much  discomfort,  is  the  most  apt  of  all  valvular  diseases  to  cause 
sudden  death,  mitral  stenosis  ranking  close  in  this  respect.  It  is  most 
severe  when  suddenly  developed  (Loomis'  Practical  Medicine),  and 
grave  when  followed  by  signs  of  mitral  insufficiency,  dilatation,  heart 
failure,  renal,  or  other  visceral  disease.  Death  may  occur  from  these  or 
from  cerebral  anaemia  and  syncope,  from  cerebral  apoplexy  or  embolism, 
or  from  asphyxia  due  to  pulmonary  congestion  and  oedema. 

Mitral  stenosis  renders  the  patient  liable  to  pulmonary  congestion, 
oedema,  or  apoplexy,  and  not  infrequently  ends  in  sudden  cardiac  failure. 

In  mitral  regurgitation,  the  prognosis  is  fairly  good  as  compensatory 
hypertrophy  is  usually  equal  to  the  necessity,  at  least  for  some  time. 
Danger  results  from  its  failure  and  consequent  general  venous  engorge- 
ment, giving  rise  to  dropsy  of  the  lungs,  serous  cavities,  and  limbs. 
Death  from  heart  failure  or  from  asphyxia  naturally  follows,  but  only 
about  two  per  cent  of  patients  with  mitral  disease  die  suddenly. 

Tricuspid  stenosis  and  lesions  of  the  pulmonary  orifice  are  seldom 
met  with,  but.  when  present,  are  necessarily  grave  conditions. 

Tricuspid  regurgitation  is  exceedingly  grave,  whether  the  result  of 


CHRONIC  ENDOCARDITIS.  229 

chronic  pulmonary  disease  or  secondary  to  lesions  of  the  left  heart.  In 
this  condition,  sudden  increase  in  the  pulmonary  engorgement  and 
death  from-  suffocation  is  a  constant  danger. 

The  symptoms  usually  indicative  of  a  fatal  issue  in  valvular  disease 
of  the  heart  are:  great  anxiety,  with  sense  of  oppression,  followed  hy 
pallor,  vertigo,  syncope,  and  muscular  debility,  and  irregular,  weak, 
intermittent,  and  rapid  pulse  of  120  beats  or  more  per  minute,  espe- 
cially when  accompanied,  on  palpation  of  the  prascordia,  by  a  purring 
tremor.  Great  anasarca  and  fluid  effusion  into  the  serous  cavities, 
dyspnoea,  hemoptysis,  and  cyanosis  are  bad  signs. 

Treatment. — In  the  treatment  of  valvular  lesions,  three  things  are 
constantly  to  be  borne  in  mind.  The  labor  of  the  heart  must  be  ren- 
dered as  light  as  possible,  the  blood  must  be  kept  in  a  healthy  condition, 
and  the  strength  of  the  heart  must  be  maintained. 

With  the  first  object  in  view,  we  interdict  rapid  walking,  running, 
or  heavy  lifting,  and  enjoin  the  patient  to  avoid  climbing  stairs,  and 
indeed  every  act  or  form  of  exercise,  mental  or  physical,  which  causes 
dyspnoea  and  palpitation.  We  attempt  also  by  proper  treatment  to  re- 
move all  obstruction  to  the  circulation;  hence,  pulmonary  and  other  dis- 
eases must  receive  appropriate  treatment.  Even  a  simple  bronchitis 
may  be  sufficient  greatly  to  obstruct  the  pulmonary  circulation.  Portal 
congestion,  or  obstruction  in  the  systemic  capillaries  which  may  be  con- 
tracted as  the  result  of  nervous  irritation  caused  by  the  retained  excreta 
in  Bright's  disease  must  be  relieved.  Eemembering  that  affections  of  the 
lungs,  liver,  alimentary  canal,  kidneys,  or  skin  may  have  caused  the 
cardiac  disease,  or  may  greatly  aggravate  it,  we  naturally  look  for 
these,  and  seek  to  combat  them  by  appropriate  treatment. 

With  the  second  object  in  view,  we  aim  to  maintain  free  elimination 
by  the  kidneys,  bowels,  and  skin,  and  recommend  vegetable  tonics,  iron, 
and  nutritious  diet,  with  regular  habits. 

To  accomplish  the  third  object,  besides  the  means  already  suggested 
for  relieving  the  heart  of  work  and  for  furnishing  it  with  proper  nutri- 
tion, we  prohibit  the  use  of  tobacco  and  of  all  other  depressing  agents 
and  administer  various  heart  tonics,  chief  among  which  are  digitalis, 
arsenic,  and  cactus  grandiflora;  belladonna  and  squills  have  a  tonic 
effect  on  the  heart  similar  to  these,  though  less  potent.  In  many  cases 
nux  vomica  is  a  most  useful  remedy. 

Other  heart  tonics  of  value,  alone  or  combined  with  digitalis,  are: 
strophanthus,  best  given  in  tincture,  TT[v.  to  x. ;  sparteine  sulphate,  gr.  -| — i ; 
caffeine  citrate,  gr.  ij.-iij.;  tincture  of  convallaria,  TT[  x.-xx. ;  and  nitro- 
glycerin. The  latter,  in  doses  of  gr.  yfj-  repeated  within  twenty  minutes 
if  necessary,  is  of  special  value  when  a  prompt  cardiac  stimulant  is  needed. 
Amyl  nitrite  acts  in  a  similar  manner.  Sparteine  seems  of  most  value, 
when  given  in  full  doses,  in  regulating  the  rhythm  of  the  heart.  Though 
the  remedies  directed  to  the  heart  itself  are  of  the  greatest  service  in  the 


230  CARDIAC  AND  ARTERIAL  DISEASES. 

treatment  of  valvular  disease,  they  should  not  be  used  indiscriminately, 
for  the  apparent  weakness  may  sometimes  be  much  more  effectually  over- 
come by  medicines  which  act  upon  some  other  organ.  Moderate  exercise 
is  sometimes  of  great  value  in  maintaining  the  strength  of  the  heart 
muscle. 

In  aortic  obstruction  or  regurgitation,  it  is  especially  important  to 
avoid  taxing  the  power  of  the  heart,  and  to  maintain  its  strength  by 
cardiac  tonics  and  a  good  supply  of  rich  blood.  Nature  always  attempts 
to  compensate  for  the  obstruction  or  regurgitation  by  hypertrophy  of 
the  left  ventricle ;  but  a  time  finally  comes  when  the  compensation  fails, 
then  digitalis  should  be  given  to  strengthen  the  muscular  walls.  Ten 
minims  of  the  tincture  three  times  a  day  is  the  ordinary  dose,  but  the 
amount  may  be  gradually  increased  until  the  heart  pulsates  regularly 
and  with  normal  force,  providing  the  kidneys  act  freely  and  the  stomach 
is  not  deranged.  Twenty  minims  may  be  given  as  often  as  every  two 
hours,  without  danger,  if  there  is  a  free  secretion  of  urine;  but  if  the 
flow  stops,  the  digitalis  must  be  at  once  suspended. 

When  compensation  is  complete,  so  that  the  heart  beats  regularly 
and  with  normal  force  and  frequency,  good  hygienic  surroundings,  with 
regulation  of  diet  and  exercise,  are  all  that  is  needed.  Exaggerated  hy- 
pertrophy with  too  powerful  systole  demands  cardiac  sedatives. 

In  mitral  obstruction  or  regurgitation,  digitalis  is  usually  most  bene- 
ficial. It  should  be  given  as  just  recommended  for  aortic  disease.  When 
it  loses  its  effect,  arsenious  acid  or  mix  vomica  should  be  tried,  alone  or 
with  the  digitalis.  Other  diuretics,  vapor  or  hot-air  baths,  and  cathartics 
will  be  required  from  time  to  time,  to  relieve  pulmonary  congestion  and 
cede  ma  or  general  dropsy. 

From  the  experiments  of  Germain  See  {La  Tribune  Medicate,  1890) 
lactose,  a  well-known  constituent  of  milk,  appears  to  be  diuretic.  Cal- 
omel in  small  doses  is  also  a  stimulant  of  the  renal  function  and  is 
specially  indicated  when  the  liver  is  engorged. 

It  is  important  to  continue  the  use  of  cardiac  tonics  in  medium  doses 
two  or  three  times  a  day,  for  many  months  after  the  distressing  symptoms, 
for  which  the  physician  was  first  called,  have  passed  away;  but  the 
amount  must  always  be  carefully  regulated,  so  as  not  to  over-stimulate 
the  organ. 

Disease  of  the  pulmonary  valves  requires  similar  treatment  to  that 
recommended  for  mitral  affections. 

In  tricuspid  regurgitation,  the  same  general  rules  laid  down  for  the 
treatment  of  other  valvular  lesions  are  to  be  followed;  but  unless  mitral 
disease  coexists,  digitalis  will  do  more  harm  than  good,  by  increasing 
the  venous  congestion  of  the  brain  and  of  the  abdominal  organs. 


MYOCARDITIS.  231 

MYOCARDITIS. 

Myocarditis  or  inflammation  of  the  muscular  fibres  of  the  heart  may 
be  acute  or  chronic. 

Anatomical  and  Pathological  Characteristics. — The  usual  seat 
of  myocarditis  is  the  wall  of  the  left  ventricle.  Very  acute  inflamma- 
tion is  marked  by  infiltration  and  swelling  of  the  muscular  fibres  to- 
gether with  their  sheaths,  and  tends  to  their  rapid  disorganization  and 
the  formation  of  small  abscesses  circumscribed  by  connective-tissue 
proliferation.  Exceptionally  the  process  ends  in  diffuse  purulent  infil- 
tration. 

Abscesses  weaken  the  wall  of  the  heart,  give  rise  to  dilatation,  rupture, 
or  aneurism  of  the  organ,  and  may  themselves  discharge  into  the  peri- 
cardial sac,  producing  pyo-pericardium,  or  into  the  ventricle,  causing 
pyaemia. 

Chronic  myocarditis  is  essentially  interstitial,  and  eventuates  in  cir- 
rhosis, making  the  organ  larger  and  heavier  than  normal,  varying  in  color 
from  gray  or  pink  to  a  bluish  hue.  The  muscle  becomes  tough  and  in- 
elastic and  either  increased  in  thickness  or  attenuated.  The  process  is 
gradual,  and  may  begin  in  the  parts  adjacent  to  the  endocardium  or  the 
pericardium  or  may  primarily  involve  the  intermuscular  septa. 

New  cells,  tending  to  organize,  produce  pressure — atrophy  of  the  mus- 
cular fibres  or  fatty  degeneration  from  disturbed  nutrition.  The  growth 
of  fibroid  tissue  may  be  so  extensive  as  largely  to  replace  muscular 
elements,  or  it  may  exist  only  as  cicatrices,  scattered  at  irregular  inter- 
vals, commonly  most  marked  at  the  apex  (Hamilton,  Text-Book  of 
Pathology) . 

As  a  result,  the  affected  wall  is  tough  and  leathery,  either  distinctly 
attenuated  or  much  thickened  and  of  a  gray  color.  This  fibroid  tissue 
sometimes  undergoes  calcification.  The  entire  wall  of  an  auricle  has 
been  found  in  such  a  condition. 

Etiology. — Acute  myocarditis  is  usually  of  septic  origin,  either  oc- 
curring as  a  part  of  pyaemia  or  developed  in  the  course  of  typhoid  or 
other  infectious  fevers.  The  chronic  form  usually  accompanies  rheu- 
matic endocarditis  aud  pericarditis,  but  may  occur  alone.  Huber,  how- 
ever, holds  that  it  rather  follows  arterio-sclerosis  of  the  coronary  artery. 
Syphilis  may  also  produce  it  (Hamilton,  op.  cit,). 

Symptomatology. — Acute  myocarditis  is  a  rare  affection,  and  of  its 
symptoms  and  signs  we  know  little,  apart  from  its  association  with  en- 
docarditis or  pericarditis.  If,  during  the  progress  of  either  of  these 
diseases,  the  heart's  action  becomes  intermittent  or  irregular,  and  there 
is  a  tendency  to  syncope,  it  is  probable  that  the  muscular  tissue  of  the 
organ  has  become  involved. 

The  symptoms  and  signs  frequently  observed  are:  extreme  pallor  of 
the  countenance,  with   coldness  of  the  surface  and  a  tendency  to  syn- 


232  CARDIAC  AND   ARTERIAL  DISEASES. 

cope;  also  pain  and  oppression  at  the  prsecordia,  with  dyspnoea  amount- 
ing to  orthopnoea,  and  sighing  respiration.  The  action  of  the  heart  is 
feeble,  fluttering,  and  irregular.  The  area  of  cardiac  dulness  remains 
normal  unless  dilatation  or  pericardial  effusion  exists.  Both  sounds  of 
the  heart  are  sharp  and  valvular,  the  first  very  closely  resembling  the 
second.  They  may  sometimes  be  represented  by  the  ta,  ta  characteristic 
of  the  foetal  heart.  With  these  symptoms  and  signs,  the  patient  may 
complain  of  severe  pain  in  the  head  and  limbs,  and  there  may  be  de- 
lirium or  hemiplegia.  All  or  only  a  part  of  these  may  be  present  or 
absent. 

The  symptoms  of  chronic  myocarditis  or  fibroid  disease  of  the  heart 
most  frequently  noticed  are  cardiac  pain,  oedema,  and  dyspnoea,  but  all 
of  these  may  be  absent. 

The  signs  are :  a  weak,  irregular,  and  rapid  pulse  and  feeble  apex-beat, 
with  coincident  enlargement  of  the  cardiac  area  of  dulness.  Reduplica- 
tion of  the  first  sound  is  also  sometimes  present. 

Diagnosis. — If  an  acute  affection  of  the  heart  is  attended  with  pallor 
and  coldness  of  the  surface,  syncope,  pain  in  the  cardiac  region,  and  a 
feeble,  fluttering,  and  irregular  pulsation,  we  may  fairly  suspect  acute 
inflammation  of  its  muscular  walls. 

Neither  the  symptoms  nor  the  signs  nor  these  combined  are  sufficient 
to  distinguish  accurately  fibroid  disease  of  the  heart  from  dilatation  or 
fatty  degeneration.  In  both,  marked  feebleness  of  the  heart  is  present; 
in  fatty  degeneration,  the  heart  is  not  so  commonly  enlarged  as  in  the 
diffuse  fibroid  disease;  the  former  is  usually  associated  with  anaemia,  the 
latter  with  general  sclerosis,  chronic  nephritis,  or  syphilis. 

According  to  Riegel,  the  pathognomonic  sign  of  chronic  myocarditis  is 
irregularity  of  action  of  the  heart,  a  total  loss  of  rhythm  appearing  early  in  the 
disease  and  remaining  irrespective  of  the  influence  of  digitalis  and  other  agents 
in  restoring  the  functional  activity  of  the  organ  and  dispelling  dropsy  and  other 
symptoms  of  deficient  heart  power  (Zeitschrift  fUr  klinische  Medicin,  1889). 
Irregularity,  though  a  feature  of  many  other  cardiac  conditions,  is  in  them  al- 
ways a  late  symptom,  due  to  secondary  weakness,  and  it  disappears  when  heart 
tonics  have  been  effective. 

Prognosis. — Theoretically,  the  prognosis  in  myocarditis  is  always 
grave,  especially  in  the  acute  form.  Practically,  a  satisfactory  prognosis 
is  rarely  possible,  because  an  accurate  diagnosis  can  seldom  be  made. 
When  occurring  with  endocarditis  and  pericarditis,  it  adds  to  the  danger 
of  death  from  heart  failure,  cardiac  aneurism  or  rupture,  or  from  pul- 
monary congestion  and  oedema,  or  embolism  and  pyaemia.  The  chronic 
form  may  terminate  in  general  dropsy  or  in  death  from  cerebral  anaemia. 

Treatment. — The  treatment  for  myocarditis  is  that  for  its  associated 
and  frecmently  causative  diseases. 

Patients  suffering  from  endocarditis,  pericarditis  or  any  obscure  heart 
trouble,  from  typhoid  fever  or  other  debilitating  diseases,  in  whom  myo- 


MYOCARDITIS.  233 

carditis  may  be  even  remotely  suspected  require:  perfect  rest  in  the  re- 
cumbent position;  avoidance  of  all  mental  or  bodily  strain;  nutritious 
and  easily  assimilated  diet;  the  maintenance  of  elimination  from  skin, 
bowels,  and  kidneys  and  moderate  stimulation  of  the  failing  heart 
with  alcoholics,  strychnine,  digitalis,  the  ammonium  compounds,  or 
nitrites. 


CHAPTER  XIV. 
CARDIAC   AND   ARTERIAL  DISEASES.— Continued. 

SIMPLE   CARDIAC    HYPERTROPHY. 

Synonyms. — Enlargement  of  the  heart;  hypersarcosis  cordis. 

Simple  cardiac  hypertrophy  consists  of  hypertrophy  of  the  muscular 
walls  of  one  or  more  of  the  cardiac  cavities  without  enlargement  of  the 
cavity  itself. 

Anatomical  axd  Pathological  Characteristics. — Simple  car- 
diac hypertrophy  unattended  by  dilatation  is  comparatively  rare  and  is 
seldom  general.  It  may  be  localized  in  any  part  of  the  cardiac  muscle, 
but  it  affects  the  wall  of  the  ventricle  more  frequently  than  that  of  the 
auricle,  being  oftenest  confined  to  the  left  side.  The  interventricular 
septum  is  not  usually  much  implicated.  In  well-marked  cases  the  organ 
is  always  large  and  heavy,  and  changed  in  shape  according  to  the  seat 
of  hypertrophy.  The  wall  is  not  uncommonly  doubled  in  thickness.  It 
is  redder  and  more  rigid  than  normal,  the  enclosed  cavities  remaining 
patulous  after  death.  The  affected  wall  of  the  left  ventricle  will  be 
extra-friable;  that  of  the  right,  tough  and  leathery  (Loomis'  Practical 
Medicine).  The  hypertrophy  results  from  increase  in  the  muscular 
structure  of  the  heart,  whether  in  number  or  size  of  the  individual  fibres 
or  in  both.  The  increase  does  not  involve  the  connective  tissue  to  any 
extent  in  simple  hypertrophy,  but  may  extend  to  the  columnar  carnese, 
especially  of  the  left  ventricle. 

Etiology. — Simple  cardiac  hypertrophy  may  arise  from  functional 
over-action  of  the  heart,  due  to  prolonged  or  severe  muscular  efforts,  to 
nervous  or  mental  causes,  or  to  the  effects  of  alcohol,  tea,  and  coffee.  It 
may  result  from  slight  obstruction  at  the  valvular  orifices  or  to  embar- 
rassment of  the  heart's  action  from  displacement  or  pericardial  adhesions. 
It  may  be  produced  by  obstructed  circulation  outside  the  heart,  as  from 
constriction  of  great  vessels  or  pressure  upon  them;  from  degenerative 
changes  of  the  arterial  system,  such  as  endarteritis  obliterans,  atheroma, 
and  loss  of  elasticity  ;  or  it  may  be  caused  by  the  obstruction  resulting 
from  contraction  of  the  arterioles  associated  with  Bright's  disease,  alco- 
holism, and  syphilis.  It  may  be  due  to  local  or  to  visceral  disease,  as  em- 
physema, cirrhosis  of  the  lung,  or  pleural  effusions  which  interfere  with 
the  pulmonary  circuit.  Physiological  cardiac  hypertrophy  occurs  in 
pregnancy. 

Symptomatology.— The  symptoms  are  not  marked,  though  there  is 


SIMPLE  CARDIAC  HYPERTROPHY.  235 

a  tendency  to  cerebral  hyperemia,  and  palpitation  on  exertion  or  excite- 
ment; a  dry  cough  may  be  present  at  times,  from  slight  pulmonary  con- 
gestion. 

The  signs  in  this  affection  vary  with  the  extent  of  the  hypertrophy, 
and  with  the  portion  of  the  organ  involved.  The  essential  signs  are: 
increased  area  of  dulness  and  increased  force  of  impulse  while  the  heart's 
action  remains  regular. 

Inspection  in  children  frequently  reveals  a  prominence  of  the  pre- 
cordial region  when  the  hypertrophy  is  general,  but  in  adults  this  can- 
not be  detected.  The  action  of  the  heart  is  regular  and  forcible.  If 
the  left  ventricle  alone  be  hypertrophied,  the  apex  beat  will  be  farther 
than  usual  to  the  left,  and  the  visible  area  of  the  impulse  increased,  often 
extending  over  the  whole  precordia.  If  the  right  ventricle  is  affected, 
there  will  be  strong  epigastric  pulsation,  and  the  apex  beat,  if  percepti- 
ble, will  be  below  and  to  the  right  of  the  usual  position. 

Palpation  confirms  the  signs  as  to  the  position  and  force  of  the  apex 
beat. 

On  percussion,  the  areas  of  superficial  and  deep-seated  cardiac  dulness 
are  found  to  be  increased.  The  latter  in  simple  hypertrophy  of  the 
left  ventricle  seldom  extends  more  than  an  inch  to  the  left  of  the  nor- 
mal position.  A  larger  area  is  almost  always  associated  with  more  or 
less  dilatation.  In  hypertrophy  of  the  right  ventricle,  the  dulness  ex- 
tends considerably  to  the  right  of  the  sternum. 

In  hypertrophy  of  the  ventricles,  auscultation  finds  the  first  sound 
of  the  heart  greatly  increased  in  intensity,  and  the  elements  of  muscular 
contraction  and  impulsion  are  especially  marked.  The  second  sound  is 
also  increased  in  intensity  and  more  widely  diffused  than  normal.  The 
action  of  the  heart  remains  regular  as  long  as  hypertrophy  compensates 
for  the  obstruction. 

The  respiratory  murmur  is  diminished  or  absent  over  a  portion  of  the 
precordial  region  corresponding  to  the  displacement  of  the  lung. 

Diagnosis. — Simple  cardiac  hyjDertrophy  may  be  confused  with  sev- 
eral affections,  which  will  be  considered  to  better  advantage  under  diag- 
nosis of  hypertrophy  and  dilatation  of  the  heart,  from  which  it  is  distin- 
guished by  the  larger  size  of  the  heart  and  greater  irregularity  of  action, 
with  more  of  a  heaving  impulse  in  the  latter.  Again,  in  hypertrophy  and 
dilatation  of  the  heart,  valvular  murmurs  are  more  commonly  present 
than  in  simple  hypertrophy;  otherwise  the  symptoms  and  signs  of  the 
two  affections  are  substantially  alike. 

Peogxosis. — Simple  cardiac  hypertrophy  as  a  compensatory  process 
is  usually  favorable,  providing  the  causative  factors  be  not  such  as  to 
produce  eventual  cardiac  or  vascular  degeneration  by  their  persistence 
or  progressiveness.  Cases  dependent  simply  upon  mental  or  muscular 
excitement  are  not  serious  under  a  properly  regulated  mode  of  life. 
When  there  is  a  marked  tendency  to  cerebral  congestion,  especially  in 


236  CARDIAC  AND   ARTERIAL   DISEASES. 

alcoholic  subjects  or  those  in  whom  arterial  degeneration  has  taken 
place,  this  affection  is  liable  to  eventuate  in  cerebral  apoplexy. 

Treatment. — Usually,  hypertrophy  of  the  heart  should  be  favored 
rather  than  retarded;  but  in  some  instances,  symptoms  of  cerebral  con- 
gestion appear  such  as  pain,  fulness  of  the  head  and  vertigo,  which  re- 
quire prompt  attention.  Bleeding  will  temporarily  relieve  these,  but  it 
is  not  to  be  recommended.  Tincture  of  aconite  root  in  doses  of  two  or 
three  drops  every  two  hours  until  relief  is  obtained  is  the  most  efficient 
remedy  in  such  instances.  Veratrum  viride  may  be  used  for  the  same 
purpose. 

It  must  not  be  forgotten  that  similar  symptoms  are  caused  by  pas- 
sive congestion  depending  upon  cardiac  failure,  and  that  in  such  cases 
the  aconite  would  be  harmful.  These  latter  cases  I  have  found  most 
quickly  relieved  by  mix  vomica.  The  causes  of  the  hypertrophy  should 
be  sought  and  removed  as  far  as  possible. 

HYPERTROPHY   AND  DILATATION   OF   THE   HEART. 

Hypertrophy  and  dilatation  of  the  heart,  also  called  eccentric  cardiac 
hypertrophy,  affecting  the  muscular  walls  and  dilating  the  cavities,  is 
caused  by  yielding  of  the  walls  to  excessive  pressure,  which  may  result 
from  the  same  causes  which  induced  the  hypertrophy,  or  from  regurgita- 
tion of  blood  through  incompetent  valves. 

Symptomatology. — Dyspnoea  on  exertion,  oedema  especially  of  the 
ankles,  and  occasional  vertigo,  and  palpitation  of  the  heart  are  common 
symptoms.  In  this  affection,  the  action  of  the  heart  remains  regular  if 
the  hypertrophy  is  sufficient  to  compensate  for  the  dilatation;  but  it 
becomes  irregular  if  the  dilatation  predominates. 

The  essential  signs  are :  increased  area  of  visible  impulse,  with  dis- 
placement of  the  apex  beat  downward  and  to  the  left,  and  a  peculiar 
heaving  impulse  with  increased  area  of  dulness.  Endocardial  murmurs 
are  nearly  always  present. 

Inspection  and  palpation  show  that  the  area  over  which  the  cardiac 
impulse  may  be  seen  and  felt  is  greatly  increased,  sometimes  extending 
over  the  entire  left  side.  The  impulse  often  has  a  peculiar  heaving  or 
lifting  character,  sufficient  in  some  instances  to  shake  the  bed  on  which 
the  patient  is  lying.  The  apex  beat  may  sometimes  be  two  or  three 
inches  to  the  left  of  the  left  nipple,  and  as  low  as  the  eighth  rib. 

Upon  percussion,  the  area  of  dulness  is  increased  to  the  left  and 
downward,  in  proportion  to  the  enlargement  of  the  organ;  if  the  right 
ventricle  is  affected,  it  is  also  increased  to  the  right. 

In  auscultation,  both  sounds  of  the  heart  are  prolonged,  and  may 
often  be  heard  over  the  entire  chest.  If  valvular  murmurs  are  present, 
they  will  be  loudest  in  the  normal  areas,  described  in  a  previous  chapter 
(Fig.  32),  but  they  may  also  be  heard  in  some  instances  over  the  whole 
thorax. 


HYPERTROPHY  AND  DILATATION  OF  THE  HEART.       237 

Diagnosis. — Eccentric  cardiac  hypertrophy  may  be  mistaken  for  re- 
traction or  consolidation  of  the  lung,  cardiac  dilatation,  pericardial 
effusion,  cardiac  displacement,  thoracic  aneurism,  or  for  simple  cardiac 
hypertrophy. 

Retraction  of  the  Jung  due  to  pleuritic  adhesions  or  pulmonary  cir- 
rhosis, by  exposing  a  larger  surface  of  the  heart,  may  increase  the  area 
of  superficial  cardiac  dulness  and  thus  simulate  hypertrophy;  but  the 
history  of  former  trouble,  pulmonary  symptoms  and  signs  of  more  or  less 
prominence,  and  the  normal  condition  of  the  pulse,  heart  sounds,  and 
force  of  the  apex  beat  distinguish  it  from  cardiac  hypertrophy.  The 
distinctive  features  between  eccentric  cardiac  hypertrophy  and  consoli- 
dation of  the  lung  are  as  follows: 

Hypertrophy  and  dilatation  of  Consolidation  of  the  lung, 

the  heart. 

Symptoms. 
Cough  not  prominent.  Cough  prominent. 

Inspection. 
Impulse   at   apex  foi'cible,  action  tu-  Force  of  apex  beat  normal, 

multuous. 

Palpation. 
Pulse  full  and  strong.  Pulse  normal  or  weak  and  rapid. 

Percussion. 
Outline  of  dulness  quadrilateral  and  Outline  irregular  and  extending  be- 

confined  to  przecordia.  yond  the  limits  of  the  heart. 

Auscultation. 
Heart  sounds  intensified.  Heart    sounds    normal.      Bronchial 

breathing,  bronchophony,  and  rales. 

Eccentric  cardiac  hypertrophy  differs  from  dilatation  of  the  heart  as 
below : 

Hypertrophy  and  dilatation  of  Dilatation  of  the  heart, 

the  heart. 

Symjjtoms. 
Symptoms  of  cerebral  hyp.eE3e.mia.  Progressive   general   weakness,  and 

oedema  of  feet. 
Inspection. 
Face   flushed  ;   carotids    prominent ;  Face  pale  or  livid,  veins  turgid,  per- 

apex  beat  heaving  and  forcible,  and        haps  pulsating    jugulars  ;   apex  beat 
distinct  over  large  area.  feeble,  not  always  visible,  though  it 

may  be  seen  over  an  area  larger  than 
usual, but  less  than  that  of  hypertrophy 
and  dilatation. 
Palpation . 
Apex  beat  forcible ;  pulse  full   and  Apex    beat    diffused,    weak  ;    pulse 

strong.  weak  and  irregular. 

Auscultation. 
Sounds  intensified  ;  first  sound  pro-  Sounds  feeble,  and  first  sound  short, 

longed . 


238  CARDIAC  AND  ARTERIAL  DISEASES. 

Eccentric  cardiac  hypertrophy  and  pericardial  effusion  and  hydro- 
pericardium  have  the  following  distinctions: 

Hypertrophy  and  dilatation  of  Pericardial  effusion. 

the  heart. 

Symptoms. 

Slowly  developed  and  not  prominent.  Symptoms  acute  in  pericarditis. 

Palpation. 
Apex   beat  strong,  displaced  to  the  Apex  beat  weak,  carried  slightly  to 

left,  and  depressed.  left  and  apparently  raised. 

Percussion. 
Outline  of  dulness  quadrilateral,  and  Outline  triangular,  and  extending  to 

not  extending  to  left  of  apex  beat.  left  of  apex  beat. 

Auscultation. 

Heart  sounds  distinct.  Sounds  feeble. 

No  friction  sounds.  Friction  sounds  have  been  present  in 

pericarditis,  and  may  be  still,  at  base  o/ 

heart. 

Eccentric  cardiac  nypertrophy  and  cardiac  displacement  differ  thus: 

Hypertrophy  and  dilatation*  of  Cardiac  displacement, 

the  heart. 

Symptoms. 
Cerebral  hyperaemia.  None  characteristic. 

Palpation. 

Heaving  apex  beat  over  great  area.  Apex   beat    of   normal   force  :   area 

not  necessarily  enlarged. 

Percussion. 

Area  of  dulness  increased.  Area  of  dulness  not  necessarily  in- 

creased. 

Auscultation. 
Sounds  intensified.  Sounds  normal. 

Eccentric  cardiac    hypertrophy  differs  from   thoracic   aneurism   as 
shown  below: 

Hypertrophy  and  dilatation  of  Thoracic  aneurism, 

the  heart. 

Symptoms. 
No   aphonia,    dysphagia,    or    boring  Boring   pain,    dysphagia,    aphonia, 

pain.  etc.,  due  to  pressure. 

Palpation. 

Impulse  heaving  and  below  fourth  Impulse   dilating  and  above  fourth 

rib.  rib.     Aneurismal  thrill. 


DILATATION  OF  THE  HEART.  239 

Hypertrophy  and  dilatation  of  Thoracic  aneurism. 

the  heart. 

Percussion. 
Dulness  increased   to  the    left    and  Dulness  increased  upward, 

downward. 

Auscultation. 
Heart  sounds  intensified.  Bruit  ;  heart  sounds  normal. 

Prognosis. — The  prognosis  dejDends  largely  upon  the  removability 
of  the  cause,  or,  if  this  is  permanent,  upon  its  progressive  or  non-pro- 
gressive character.  Existing  hypertrophy,  though  sufficient  to  meet  the 
ordinary  demands  of  the  case  for  years,  may  be  rendered  inefficient  by 
undue  muscular  strain,  exhausting  diseases,  great  and  continued  emo- 
tional disturbances,  or  in  seme  cases  by  pregnancy;  the  latter  condition, 
however,  is  not  contra-indicated  in  moderate  cases. 

When  great  force  must  be  habitually  exerted  by  the  ventricle  to 
overcome  increased  resistance  due  to  obstruction  or  regurgitation,  the  evil 
effects  are  apt  to  be  manifested  in  chronic  congestion  of  the  lungs,  in 
degeneration  of  the  arteries  generally,  or  in  rupture  of  cerebral  vessels 
which  may  already  be  the  seat  of  atheroma. 

Treatment. — The  treatment  of  this  condition  is  essentially  that  of 
chronic  endocarditis  with  valvular  disease  of  the  heart,  with  which  it  is 
nearly  always  associated. 

As  long  as  hypertrophy  is  perfectly  compensatory,  no  treatment  is 
demanded  except  in  case  of  excessive  cerebral  congestion,  with  danger  of 
apoplexy,  when  cardiac  sedatives  are  indicated.  Otherwise  the  hygienic 
and  medicinal  treatment  suggested  for  disease  of  the  heart  should  be 
carried  out. 

DILATATION    OF   THE   HEABT. 

Synonym*. — Passive  aneurism  of  the  heart;  cardiectasis;  cardiac 
dilatation. 

ANATOMICAL    AXD    PATHOLOGICAL   CHARACTERISTICS. — dilatation  of 

the  heart  refers  to  an  abnormal  increase  in  the  cavities  of  the  heart,  irre- 
spective of  the  condition  of  its  walls,  which  may  be  relatively  normal  or 
attenuated.  The  auricles  are  most  frequently  affected,  and  the  right 
ventricle  oftener  than  the  left.  The  shape  of  a  dilated  heart  depends 
upon  the  amount  of  dilatation,  and  upon  the  cavity  or  cavities  involved. 
The  shape  may  be  irregular  from  bulging  of  a  single  auricle  or  ventricle; 
or  more  uniformly  enlarged,  from  stretching  of  all  the  cavities.  The  walls, 
if  not  normal,  may  be  atrophic  or  slightly  hypertrophic  and  may  be  the 
seat  of  various  degenerations  or  infiltrations  according  to  the  cause  of 
the  affection. 

Etiology. — Dilatation  of  the  heart  is  dependent  upon  a  disparity 
between  the  power  of  the  cardiac  muscle  and  the  intra-cardiac  pressure. 


240  CARDIAC  AND  ARTERIAL  DISEASES. 

Old  age,  tending  to  retrogressive  change;  sex  and  occupation,  as  in- 
fluencing exposure;  and  heredity,  are  remote  factors  in  its  production. 
The  predisposing  causes  include  all  the  conditions  which  weaken  the 
walls  of  the  heart.  Prominent  among  these  is  atony  of  its  muscular 
fibres  resulting  from  anaemia,  chlorosis,  exhausting  febrile  and  infectious 
diseases;  derangements  of  innervation  incident  to  sexual,  alcoholic, 
and  other  excesses;  or  certain  nervous  disorders,  as  Graves'  disease.  The 
muscular  walls  may  be  weakened  by  degeneration.  This  may  result  from 
obstruction  of  the  coronary  artery  by  embolism,  arterio-sclerosis  or  con- 
traction of  old  pericardial  adhesions;  or  it  maybe  secondary  to  rheu- 
matic, gouty,  or  syphilitic  pericarditis,  endocarditis,  or  myocarditis;  or 
atrophy  may  occur,  due  to  old  age  or  to  pressure  from  amyloid  or  fatty 
infiltration,  new  growths,  or  chronic  pericardial  effusion.  The  exciting 
cause  of  dilatation  is  increase  of  intracardiac  pressure.  This  may  occur 
from  valvular  disease,  and  from  the  pressure  of  tumors  upon  the  aorta,  pul- 
monary artery,  or  other  great  vessels;  from  general  increase  of  arterial 
tension  associated  with  Bright's  disease;  from  obstruction  of  smaller  ves- 
sels or  stasis  incideut  to  prolonged  muscular  efforts,  or  to  fibroid  phthisis 
or  other  diseases  of  the  lungs;  or  from  local  vascular  degeneration  due 
to  alcoholism,  syphilis,  and  gout,  notably  to  endarteritis  obliterans. 

Symptomatology. — The  most  frequent  symptoms  are:  rapid  and 
feeble  or  irregular,  intermittent  pulse;  cardiac  palpitation  and  sensations 
of  ojDpression  and  uneasiness;  sighing  respiration,  dyspnoea,  and  syncope; 
dropsy,  turgescence  of  the  veins,  and  congestion  of  the  various  organs, 
causing  cedema  of  the  lungs,  jaundice,  or  albuminuria. 

The  most  important  sigm  are:  feeble  and  irregular  action  of  the 
heart;  an  enlarged  area  of  dulness,  oval  in  form,  and  not  extending  far 
to  the  left  of  the  apex  beat ;  and  feebleness  of  the  heart  sounds. 

On  inspection,  the  impulse  of  the  Heart's  apex  may  not  be  visible. 
If  seen  at  all,  it  is  likely  to  extend  over  a  wider  area  than  in  health,  and 
the  point  of  maximum  intensity  is  not  easily  determined.  It  is  occa- 
sionally of  an  undulatory  character. 

Permanent  dilatation  and  varicosity  of  the  jugular  veins  is  a  sign  of 
a  dilated  right  auricle. 

By  palpation,  the  apex  beat  is  found  below  the  normal  position  and 
to  the  left  of  it,  and  the  heart's  action  is  irregular  in  rhythm.  The  im- 
pulse is  feeble,  which  enables  us  readily  to  distinguish  this  affection 
from  hypertrophy,  or  hypertrophy  with  dilatation.  A  purring  tremor 
may  frequently  be  obtained,  especially  when  there  is  mitral  regurgita- 
tion. 

Percussion  shows  the  area  of  cardiac  dulness  increased  to  the  right 
when  the  right  cavities  are  involved,  and  to  the  left  when  the  left  cavi- 
ties are  dilated;  dulness  due  to  dilated  auricles  may  extend  upward,  even 
to  the  first  interspace. 

This  area  maintains  an  oval  outline,  which  enables  us  to  distinguish 


DILATATION  OF  THE  HEART.  -241 

the  disease  from  pericarditis,  in  which  the  signs,  upon  inspection  and 
palpation,  are  nearly  identical. 

By  auscultation  both  sounds  of  the  heart  are  found  short,  abrupt,  and 
feeble,  and  frequently  of  equal  length.  The  second  sound  may  be  in- 
audible at  the  apex,  and  the  first  may  be  reduplicated. 

If  valvular  murmurs  have  been  present,  these  become  less  intense, 
and  sometimes  of  a  swirling  character.  The  respiratory  sounds  over  the 
upper  portion  of  the  left  lung  are  often  feeble. 

Diagnosis. — There  is  usually  little  difficulty  in  distinguishing  dila- 
tation of  the  heart  from  all  other  affections,  excepting  pericarditis. 
The  distinctive  features  between  these  two  are  as  follows : 

Dilatation  of  the  heart.  Pericarditis. 

History. 
Chronic.  Acute. 

Palpation. 

Impulse  feeble  and    irregular,    felt  Impulse    feeble    and   irregular,  felt 

below  and  to  the  left  of  its  normal  posi-  above  its  normal  position,  and  increased 
tion,  and  not  materially  affected  by  in  force  when  the  patient  leans  for- 
leaning-  the  patient's  body  forward.  ward. 

Percussion. 
Oval  outline  of  dulness,  which  does  Triangular  outline  of  dulness,  which 

not  extend  far  to  the  left  of  the  apex.  extends  considerably  to  the  left  of  the 

apex  beat. 

Auscultation. 
Heart  sounds  feeble,  short,  and  val-  Heart  sounds     feeble,    and     not    so 

vular,  and  not  altered  by  position.  markedly  valvular,  but  intensified  by 

leaning  the  body  forward. 


Asystolism  is  a  term  which  has  been  applied  to  a  condition  in  which 
the  ventricle  cannot  completely  empty  itself.  It  is  nearly  always  asso- 
ciated with  dilatation  of  the  right  ventricle. 

In  this  condition,  the  impulse  of  the  heart  becomes  very  feeble,  and 
shortly  before  death  the  valvular  sounds  or  murmurs  which  may  have 
been  present  become  almost  inaudible,  or  they  may  be  supplanted  by  a 
continuous  humming  sound.  Tricuspid  regurgitation,  with  pulsation 
in  the  jugular  veins,  is  likely  to  be  developed  during  the  course  of  this 
affection. 

Prognosis. — The  prognosis  is  unfavorable  according  as  dilatation  rel- 
atively exceeds  compensatory  hypertrophy,  the  gravity  depending  upon 
degenerations  of  the  muscular  wall,  and  upon  the  degree  of  obstruction 
to  circulation.  When  compensation  is  good  and  no  complications  exist, 
the  patient  may  live  for  years;  but  associated  valvular  lesions,  pulmonary 
affections,  Bright's  disease,  general  anaemia,  hereditary  predisposition 
16 


242  CARDIAC  AND  ARTERIAL  DISEASES. 

to  heart  disease,  and  weakness  from  any  cause  render  the  prognosis  un- 
favorable. 

Dyspnoea  and  irregular  and  intermittent  pulse,  tendency  to  dropsy, 
and  syncope  are  grave  signs,  indicating  that  death  may  occur  suddenly 
at  any  time,  though  the  patient  may  linger  for  several  months. 

Treatment. — The  treatment  of  dilatation  of  the  heart  and  of  asys- 
tolism  should  be  the  same  as  that  recommended  for  chronic  endocarditis 
with  valvular  disease  of  the  heart. 

Though  the  dilated  cavities  cannot  be  reduced  to  normal,  compensa- 
tory hypertrophy  of  the  walls  may  be  induced  and  should  be  encouraged 
by  avoiding  all  unnecessary  exertion;  by  improving  general  nutrition 
with  an  abundance  of  easily  digested  food,  tonics,  and  regulation  of  ex- 
cretion; and  by  careful  stimulation  of  the  heart  by  digitalis,  strophan- 
thus,  sparteine,  convallaria,  or  caffeine,  and  in  suitable  cases  by  moderate 
exercise. 

ATROPHY   OF  THE    HEART. 

Synonym. — Phthisis  of  the  heart. 

Atrophy  of  the  heart  is  an  extremely  rare  affection.  It  consists  of 
simple  attenuation  of  the  walls  of  the  heart,  the  cavities  usually  remain- 
ing of  normal  size,  but  in  some  cases  both  the  thickness  of  the  walls 
and  the  size  of  the  cavities  are  diminished. 

The  affection  is  sometimes  congenital.  It  may  be  caused  by  old  age, 
chronic  wasting  disease,  or  by  constriction  of  the  coronary  arteries. 

Diagnosis. — A  diagnosis  can  rarely,  if  ever,  be  made  during  life; 
but  in  the  congenital  variety  we  may  possibly  detect  decreased  area  of 
cardiac  dulness  independent  of  pulmonary  emphysema. 

FATTY   HEART. 

There  are  two  recognized  varieties  of  fatty  heart:  one,  in  which 
there  is  a  deposit  of  fatty  tissue  upon  the  surface  of  the  heart  or  be- 
tween its  muscular  fibres  (infiltration),  and  the  other,  in  which  the  mus- 
cular fibres  themselves  undergo  fatty  degeneration. 

Etiology. — The  first  variety  of  fatty  heart  is  attributed,  by  Kennedy, 
to  a  fatty  diathesis,  and  is  associated  with  obesity;  the  second  variety 
results  from  atheromatous  degeneration  of  the  aorta,  old  age,  alcoholism, 
gout,  or  some  prolonged  wasting  disease. 

Symptomatology. — The  symptoms  of  fatty  disease  of  the  heart  are 
practically  the  same  in  both  varieties,  and  they  are  of  the  greatest  im- 
portance from  a  diagnostic  point  of  view.  The  most  prominent  of  these 
are:  melancholia  or  irritability  of  temper,  partial  loss  of  memory,  or 
hesitating  speech ;  palpitation  of  the  heart,  dyspnoea,  and  angina  pec- 
toris.    Other  symptoms  which  are  frequently  noticed  are:  pallor  and  a 


FATTY  HEART.  243 

sallow  appearance  of  the  surface,  with  congestion  of  the  ears  and  lips; 
weight  and  pain  in  the  head;  a  sense  of  pain  in  the  epigastrium;  double 
vision  or  loss  of  vision;  and  the  arcus  senilis.  Pseudo-apoplexy,  and 
Cheyne-Stokes  respiration,  when  present,  are  symptoms  of  the  greatest 
value. 

Pseudo-apoplexy  consists  of  attacks  in  which  the  individual  suddenly 
loses  consciousness  and  falls.  It  differs  from  true  apoplexy  in  the 
rapidity  of  recovery.  When  these  attacks  first  make  their  appearance, 
they  seldom  continue  more  than  a  minute  or  two,  the  patient  coming 
out  of  them  feeling  perfectly  well ;  but,  as  the  disease  progresses,  they 
become  more  and  more  frequent,  prolonged,  and  severe,  and  are  at- 
tended with  paralysis ;  even  then  the  patient  usually  recovers  completely 
in  a  few  days  at  most. 

The  Cheyne-Stokes  respiration,  which  appears  late  in  the  disease, 
consists  in  the  occurrence  of  a  series  of  inspirations  increasing  to  a  max- 
imum, and  then  declining  in  force  and  length  until  a  state  of  apparent 
apncea  is  established.  In  this  condition  a  patient  may  remain  for  such 
a  length  of  time  as  to  make  his  attendants  believe  him  dead,  when  a 
low  inspiration,  followed  by  one  more  decided,  marks  the  commencement 
of  a  new  ascending  and  descending  series  of  inspirations.  Although  this 
is  an  important  symptom  of  fatty  heart,  it  must  not  be  forgotten  that 
it  occasionally  occurs  in  dilatation  and  in  valvular  disease  of  the  organ. 

In  fatty  infiltration  of  the  heart,  obesity  is  a  symptom  of  impor- 
tance. In  fatty  degeneration,  loss  of  weight,  after  a  person  has  been 
fleshy,  is  a  valuable  symptom. 

Among  the  signs  of  fatty  infiltration  of  the  heart,  are :  a  pulse  usually 
slow — forty  or  fifty  per  minute — full,  and  sometimes  even  bounding; 
increased  area  of  cardiac  dulness  on  very  careful  percussion. 

In  fatty  degeneration,  the  pulse  is  weak  and  irregular  and  usually 
rapid.  Auscultation  over  the  apex  will  occasionally  reveal  slow  pulsa- 
tion; and  even  when  the  pulsation  equals  seventy  per  minute,  it  often 
conveys  to  the  ear  a  sense  of  slowness. 

The  impulse  of  the  apex  is  weak,  and  the  intensity  of  the  sounds 
feeble  in  either  variety.  If  valvular  disease  coexists,  a  soft  systolic  souffle 
may  sometimes  be  detected  by  careful  auscultation  over  the  aorta. 

On  inspection  and  palpation,  the  impulse  is  either  indistinct  or  ab- 
sent; the  apex  remains  in  its  normal  position.  The  pulse  in  fatty  de- 
posit is  slow  and  full;  in  fatty  degeneration  it  may  be  slow  or  rapid, 
but  it  usually  appears  to  be  rapid  at  the  wrist,  even  though  the  heart 
is  beating  slowly. 

By  percussion,  the  heart  is  found  of  normal  size  in  uncomplicated 
fatty  degeneration,  but  slightly  enlarged  in  fatty  deposit. 

In  auscultation,  the  first  sound  is  frequently  absent,  but  if  present 
it  will  be  feeble,  short,  and  valvular,  having  lost  nearly  all  of  its  muscular 
element.     The  second  sound  is  usually  short,  clacking,  and  distant. 


2U  CARDIAC  AND  ARTERIAL  DISEASES. 

A  soft,  blowing  murmur  may  frequently  be  heard  over  the  aorta  with 
the  first  sound,  especially  if  the  patient  is  in  the  recumbent  position. 

Exceptional. — Sometimes  the  heart  sounds  in  this  disease  are  like  those  of 
the  foetus  in  utero.  Sometimes  they  are  metallic  or  ringing,  and  it  is  said  that 
the  second  sound  is  sometimes  prolonged  and  intensified. 

Stokes  considered  the  occurrence  of  pseudo-apoplexy  with  a  soft  souffle 
in  the  aortic  area,  with  the  first  sound  of  the  heart,  and  a  slow  pulse 
positive  evidence  of  fatty  degeneration  of  the  heart;  but  these  signs  are 
seldom  combined  in  the  same  individual. 

A  combination  of  several  of  the  important  symptoms  and  signs  which 
have  been  enumerated  is  often  present,  and  may  justify  a  positive  diag- 
nosis. 

Diagnosis. — The  physical  signs  are  not  always  well  marked,  and  a 
positive  diagnosis  is  often  impossible.  Fatty  heart  is  most  likely  to  be 
mistaken  for  functional  affections  of  the  organ,  from  which  it  can  only 
be  distinguished  by  careful  scrutiny  of  the  symptoms  and  signs 
already  enumerated,  and  the  exclusion  of  hysterical  affections  and  other 
functional  causes.  A  distinction  may  sometimes  be  made  by  causing 
the  patient  to  walk  briskly,  when  if  the  trouble  is  functional  the  heart's 
action  becomes  more  regular  and  stronger  and  the  sounds  more  distinct, 
whereas  if  organic  changes  are  present  the  pulsations  become  more 
irregular  and  feebler  than  before. 

Prognosis. — The  prognosis  is  unfavorable  in  fatty  degeneration. 
Fatty  infiltration,  when  excessive,  will  produce  degeneration  of  the  mus- 
cular fibres  from  pressure;  much  can  be  done  in  mild  cases  by  a  proper 
system  of  diet  and  exercise.  In  either  case,  but  especially  in  fatty  de- 
generation, death  by  syncope  is  apt  to  occur  suddenly  and  without  warn- 
ing, from  excitement,  overexertion  or  distention  of  the  stomach  or 
bowels  by  a  too  hearty  meal  or  flatulence. 

Treatment. — The  general  treatment  consists  of  cardiac  and  general 
tonics  and  is  the  same  as  for  valvular  diseases.  Patients  should  be 
cautioned  to  avoid  doing  anything  which  causes  dyspnoea. 

Arsenious  acid  is  one  of  our  best  remedies  in  cardiac  degeneration,  as 
it  not  only  increases  the  power  of  the  heart,  but  also  relieves  the  neuralgic 
pains,  which  are  among  the  most  distressing  symptoms  of  this  disease. 
When  the  affection  consists  of  fatty  deposit  on  the  surface  of  the  heart, 
or  between  its  muscular  fibres,  much  may  be  accomplished  by  regulat- 
ing the  diet.  The  patient  should  live  principally  on  lean  meat,  avoiding 
as  far  as  possible  all  fat-producing  food,  such  as  sugar,  starch,  and  alco- 
holic stimulants.  He  should  take  as  little  fluid  as  possible,  and  should 
wear  warm  woollen  clothing,  even  in  summer,  to  favor  free  diaphoresis, 
and  should  take  systematic  gentle  exercise.  These  measures  will  lessen 
obesity  and  strengthen  the  weak  muscles. 


SYPHILITIC  DISEASE  OF  THE  HEART  245 

ANEURISM   OF  THE   HEART. 

Aneurism  of  the  heart  is  a  rare  affection,  consisting  of  bulging  of 
that  portion  of  the  cardiac  walls  which  has  been  softened  by  inflamma- 
tion. It  usually  occurs  at  the  apex  of  the  left  ventricle,  and  occasion- 
ally involves  the  interventricular  septum,  bulging  into  the  right 
cavity.  Barely,  it  includes  nearly  the  entire  ventricular  wall,  which  in 
such  cases  is  thin  and  dilated,  and  chiefly  fibrous  from  loss  of  muscular 
fibre.  Occasionally  it  is  sacculated,  sometimes  reaching  the  size  of  a 
cocoanut,  and  connected  with  the  ventricle  by  a  narrow  neck.  The 
walls  vary  up  to  a  quarter  of  an  inch  in  thickness.  The  endothelium, 
though  atrophied,  usually  remains  intact.  Commonly  old  stratified  clots 
line  its  interior. 

Etiology. — Cardiac  aneurism  may  develop  from  any  condition  which 
weakens  the  wall  of  the  heart,  such  as  disease  of  the  coronary  arteries, 
fatty,  fibroid,  amyloid,  or  atrophic  degeneration,  or  abscess  whether  or 
not  the  sequelae  of  myocarditis,  endocarditis,  or  pericarditis. 

Diagnosis  axd  Prognosis. — A  diagnosis  can  seldom  be  made  before 
death,  which  usually  occurs  from  rupture  or  heart  failure  due  to  weak- 
ening of  the  muscle  or  mechanical  interference  with  its  action. 

Treatment. — The  treatment  must  be  entirely  symptomatic;  when 
there  is  much  cardiac  pain,  rest,  and  potassium  iodide  in  moderately  large 
doses  are  most  efficient.  There  are  no  symptoms  or  signs  to  distinguish 
cardiac  aneurism  from  myocarditis. 

RUPTURE   OF  THE   HEART. 

Rupture  of  the  heart  may  follow  myocarditis  or  fatty  degeneration  of 
the  heart.  In  the  latter  case,  it  seldom  occurs  in  persons  less  than  sixty 
years  of  age. 

Symptomatology. — The  symptoms  are:  sharp,  sudden  pain  in  the 
precordial  region,  faintness,  collapse,  and  speedy  death;  though  some 
patients  have  lived  forty-eight  hours  after  the  accident. 

Death  is  usually  so  sudden  that  an  examination  cannot  be  made,  but 
the  signs  must  of  necessity  be  those  of  distention  of  the  pericardium  by 
fluid,  with  extreme  weakness  of  the  heart.  Treatment  would  be  un- 
availing. 

SYPHILITIC  DISEASE  OF  THE   HEART. 

A  few  cases  have  been  observed  where  heart  disease  seemed  to  have 
resulted  from  constitutional  syphilis.  Syphilitic  affections  of  this  organ 
consist  of  fibrinous  exudations  into  the  connective  tissue,  which  may 
either  soften  and  suppurate,  forming  ulcers  or  small  abscesses,  or  be 
converted  into  masses  of  hardened  fibroid  tissue;  and  it  is  not  im- 
probable that,  as  suggested  by  Corvisart,  vegetations  on  the  valves  may 
in  some  cases  have  a  syphilitic  origin.  An  accurate  diagnosis  is  impos- 
sible.     Xo  treatment  can  be  suggested  where  a  diagnosis  cannot  be  made. 


246  CARDIAC  AND  ARTERIAL  DISEASES. 

TUMORS  OF  THE  HEART. 

The  heart  is  very  seldom  the  seat  of  neoplasms.  Congenital  angio- 
mata  may  exist  in  its  walls;  sarcomata  and  carcinomata  may  penetrate 
it  from  adjacent  organs.  Hydatids  are  rarely  found.  Of  these  no  diag- 
nosis can  be  made.  The  prognosis  is  necessarily  unfavorable  in  the  case 
of  progressive  tumors.     The  treatment  must  be  symptomatic. 

MORBUS  C^ERULEUS. 

Synonyms. — Cyanosis,  the  blue  disease. 

Morbus  Casruleus  is  the  result  of  congenital  malformation  of  the  heart. 
Cyanosis,  usually  marked  in  the  cases,  is  ascribed  to  general  venous  com 
gestion  due  to  obstruction  in  the  right  heart,  but  it  has  also  been  sup- 
posed to  result  from  admixture  of  venous  with  arterial  blood.  The 
morbid  conditions,  found  post  mortem,  may  be  j)atency  of  the  ductus 
arteriosus  or  foramen  ovale,  deficient  interventricular  septum  or  nar- 
rowing or  complete  closure  of  the  pulmonic  orifice.  Two  or  more  of 
these  abnormities  are  not  infrequently  combined,  the  first  mentioned 
being  the  defect  most  often  present. 

Symptomatology. — The  unfortunate  subjects  are  usually  small  and 
feeble  young  children.  Cyanosis  may  be  slight  or  it  may  amount  to  a  deep 
purple  or  blue  color.  It  occurs  early,  but  may  vary  at  different  times. 
The  superficial  temperature  is  low,  giving  rise  to  chilliness.  Cough, 
dyspnoea,  and  frecpient  attacks  of  palpitation  are  common,  appearing 
after  or  increased  by  exertion  or  excitement. 

As  signs,  inspection,  in  addition  to  the  blueness  of  the  surface,  often 
reveals  precordial  bulging  and  abnormal  pulsation  diffused  to  the  epi- 
gastrium. By  palpation,  especially  at  the  base  of  the  heart,  a  thrill  may 
be  obtained.  Percussion  shows  enlargement  of  the  right  heart;  dulness, 
according  to  Gerhardt,  may  often  be  elicited  along  the  left  side  of  the 
sternum,  as  high  as  the  second  rib,  owing  to  the  enlargement  of  the 
conns  arteriosus  and  distention  of  the  pulmonary  artery.  Auscultation 
may  discover  a  systolic  murmur  over  the  region  of  the  pulmonary  artery, 
and  rarely  a  diastolic  murmur.  A  systolic  murmur  during  the  first 
three  years  of  life  is  said  to  be  invariably  of  congenital  origin. 

Diagnosis.— In  the  London  Lancet,  -May,  1879,  Sansom  formulates 
the  following  propositions  relating  to  the  diagnosis  of  congenital  disease 
of  the  heart  in  children. 

First,  in  cases  of  congenital  cyanosis,  in  which  no  cardiac  murmur  is 
manifest,  there  is  probably  patency  of  the  foramen  ovale. 

Second,  in  cases  of  cyanosis  with  murmur  varying  at  intervals,  and 
heard  over  the  sternal  ends  of  the  third  and  fourth  costal  cartilages  and 
intercostal  spaces,  there  is  probably  patency  of  the  foramen  ovale. 

Third,  in  cases  of  cyanosis  with  loud,  unvarying  systolic  murmur, 
with  maximum  intensity  internal  to  the  position  of  the  apex  beat,  but 


NEUROTIC  OR  FUNCTIONAL  DISEASE  OF  THE  HEART.      24? 

heard  also  at  the  back  between  the  scapula?,  there  is  probably  imperfec- 
tion of  the  ventricular  septum. 

Fourth,  in  cases  of  cyanosis  and  of  marked  anaemia,  in  children  who 
manifest  a  pronounced  superficial  systolic  murmur  at  the  base  of  the 
heart,  there  is  probably  constriction  of  the  pulmonary  artery  at  its  ori- 
fice. Such  murmurs  may  be  associated  with  anaemic  murmurs  which  are 
heard  above  the  clavicles, 

Fifth,  in  cases  of  congenital  affection  of  the  heart  in  which  there  is 
evidence  of  considerable  dilatation  of  the  left  chambers,  it  is  probable 
that  endocarditis  affecting  the  valves  has  constituted  a  complication. 

Pkogxosis. — Most  subjects  of  congenital  malformation  of  the  heart 
live  but  a  few  hours  or  days  after  birth,  and  very  rarely  reach  advanced 
age.  The  prognosis  is  best  in  cases  of  congenital  stenosis  of  the  pul- 
monary artery. 

Tkeatmext. — No  specific  treatment  can  be  recommended,  but  the 
same  general  rules  should  be  observed  as  in  cases  of  valvular  disease  of 
the  heart. 

NEUROTIC   OR  FUNCTIONAL  DISEASE   OF  THE  HEART. 

Functional  disorders  of  the  heart  are  characterized  by  peculiar  sensa- 
tions and  by  change  in  the  frequency,  force,  or  rhythm  of  the  pulse  and 
apex  beat,  and  in  the  character  of  the  heart  sounds,  several  of  these 
being  commonly  associated. 

The  affection  ordinarily  manifests  itself  by  frequent  paroxysmal  at- 
tacks of  palpitation  and  irregularity  of  the  heart's  action.  It  is  aptly 
stated  by  Balfour,  that  if  a  patient  come  complaining  of  disease  of  the 
heart  who  has  not  obtained  the  opinion  of  a  physician,  we  may,  in  the 
•majority  of  cases,  assure  him  that  it  is  only  a  functional  affection,  and 
that  no  organic  disease  exists;  for  the  latter  generally  escapes  notice 
until  detected  by  the  physician. 

Etiology. — The  variations  from  the  normal  conditions  may  be  tran- 
sient and  paroxysmal,  or  more  or  less  constant.  They  may  arise  from 
emotional  causes,  as,  joy,  fear,  or  shock,  and  from  hysteria,  or  hypochon- 
driasis. They  are  often  associated  with  chorea,  exophthalmic  goitre,  and 
other  functional  nervous  derangements.  They  may  result  from  over-ex- 
ertion, from  the  exhausting  influence  of  acute  diseases,  or  from  reflex 
irritation,  especially  of  gastric,  hepatic,  or  intestinal  origin,  or  from 
excessive  venery.  They  may  be  due  to  anaemia  or  to  poisonous  agencies 
acting  through  the  circulation,  whether  referable  to  lithaemia,  gout, 
rheumatism,  lead  poisoning,  or  inordinate  use  of  alcohol,  tobacco,  tea, 
and  coffee.  Heredity  and  the  nervous  diathesis  are  also  potent  factors 
in  their  causation. 

Symptomatology. — Cardialgia  and  palpitation  or  a  subjective  sensa- 
tion of  the  cardiac  impulse,  are  the  most  constant  symptoms  of  func- 


248  CARDIAC  AND  ARTERIAL   DISEASES. 

tional  disease,  and  usually  give  rise  to  much  anxiety.  Abnormally  rapid 
pulse  (tachycardia)  or  abnormally  slow  pulse  (bradycardia),  or  irregu- 
larity, intermittency,  weakness,  or  fulness  of  its  beat,  and  morbid  pre- 
cordial sounds  and  sensations  frequently  occur.  Vertigo,  tinnitus  au- 
rium,  and  photophobia  are  not  uncommon,  and  marked  pseudo-angina 
pectoris  may  occur. 

Though  the  physical  signs  of  the  neurotic  affection  are  in  no  way 
characteristic,  physical  diagnosis  is  of  importance  in  excluding  organic 
disease. 

By  inspection  and  palpation  we  find  the  apex  in  its  normal  position, 
but  usually  the  impulse  is  comparatively  feeble,  though  the  stroke  may 
seem  sharp  and  quick.     The  action  of  the  heart  is  usually  irregular. 

Percussion  shows  the  heart  to  be  of  normal  size. 

In  auscultation,  both  sounds  of  the  heart  are  abrupt,  and  may  be  in- 
tensified. Occasionally  the  first  sound  has  a  metallic  character.  Fre- 
quently anaemic  murmurs  are  found  in  the  aortic  area,  and  also  in  a  space 
which  has  been  improperly  termed  the  pulmonary  area,  viz.,  a  limited 
area,  an  inch  or  an  inch  and  a  half  to  the  left  of  the  sternum,  in  the 
second  intercostal  space.  The  murmur  in  the  latter  position  is  appar- 
ently due  to  slight  mitral  regurgitation  dependent  upon  a  weakened 
condition  of  the  left  ventricle  which  allows  dilatation  to  such  an  extent 
that  the  mitral  valves  are  unable  completely  to  close  the  auriculo- 
ventricular  orifice.  In  such  cases  the  dilatation  disappears,  and  the 
murmur  ceases  as  the  muscles  regain  their  tonicity. 

Diagnosis. — It  is  of  great  importance  to  make  an  accurate  differen- 
tial diagnosis  between  functional  and  organic  heart  disease.  The  chief 
points  of  distinction  have  been  already  noted  in  the  differential  diagnosis 
of  chronic  endocarditis. 

The  symptoms  of  functional  disease  of  the  heart  may  be  associated 
with  the  signs  of  organic  lesions  merely  as  a  coincidence.  In  such  in- 
stances an  exact  diagnosis  would  be  extremely  difficult.  It  could  only 
be  made  by  repeated  careful  examinations  and  by  the  evidence  afforded  by 
treatment,  under  which  many  of  the  functional  symptoms  may  disappear. 

Prognosis. — Functional  disorders  of  the  heart  usually  continue  for 
months  or  even  years  unless  the  cause  can  be  ascertained  and  removed 
by  proper  treatment,  but  they  are  seldom  if  ever  dangerous  to  life,  if 
true  angina  pectoris  be  excepted. 

Treatment. — The  first  thing  in  these  cases  is  to  impress  upon  the 
patient  the  fact  that  his  heart  symptoms  are  not  due  to  organic  disease, 
and  that  he  is  likely  to  recover  entirely.  This  must  be  done  after  a 
careful  and  painstaking  examination.  Since  neurotic  affections  of  the 
heart  are  usually  due  to  anaemia,  hysteria,  uterine  irritation,  sexual 
abuses,  or  the  excessive  use  of  alcoholic  stimulants,  or  of  tobacco,  or  of 
tea  and  coffee,  we  should  ascertain  which  of  these  operates  in  the  case 
before  us,  and  advise  accordingly. 


TACHYCARDIA.  249 

General  tonics  are  usually  indicated.  In  a  few  cases  digitalis  will  be 
found  serviceable  in  controlling  the  action  of  the  heart,  but  sparteine 
sulphate  gr.  i/toi.,  tinct.  of  strophanthus  X\\,v.  to  x.,  tinct.  of  conval- 
laria  nix.  to  xv.,  or  fl.  ext.  of  cactus  grandifiora  ffli.  to  iv.,  three  times 
a  day  are,  as  a  rule,  more  efficient.  In  many  cases  strychnine  and  in 
others  bromides  are  specially  beneficial,  and  occasionally  nitroglycerin, 
amyl  nitrite,  aconite,  or  veratrum  viride  may  be  beneficially  employed 
in  small  doses. 

TACHYCARDIA. 

Tachycardia  is  a  term  which  may  be  broadly  applied  to  an  abnormal 
rapidity  of  the  heart,  ■  occurring  either  as  a  paroxysmal  or  as  a  more 
permanent  affection,  whether  or  not  accompanied  by  weakness,  irregular- 
ity, or  intermittency  of  the  pulse.  The  pulsations  may  run  from  one 
hundred  and  twenty  to  even  three  hundred  per  minute.  If  the  action 
is  rapid  and  the  impulse  forcible,  it  is  commonly  termed  palpitation. 

Tachycardia  may  be  a  symptom  of  organic  or  of  functional  disease; 
it  also  occurs  as  an  idiopathic  affection  and  is  occasionally  hereditary. 

In  some  instances  of  paroxysmal  tachycardia  as  described  by  L. 
Bouveret  [International  Medical  Annual,  II,  p.  252)  in  a  report  of 
eleven  collected  cases,  the  heart,  normal  in  the  intervals,  is  seized  with 
paroxysms  of  rapidity,  which,  if  the  attack  be  of  short  duration,  may 
reach  two  and  even  three  hundred  beats  a  minute.  If  these  attacks 
are  prolonged  for  several  days,  symptoms  of  cerebral  hyperemia  with 
embarrassment  of  the  pulmonary  and  systemic  circulation  commonly 
appear.  In  such  cases,  change  to  the  normal  action  may  occur  sud- 
denly, and  may  be  followed  by  decided  prostration.  Four  out  of  the 
eleven  cases  died  of  asystole  or  syncope.  Instances  of  hereditary  tachy- 
cardia have  been  known  in  which  the  heart  beat  with  infantile  rapidity 
through  life  seemingly  without  detriment  to  the  individual. 

The  so-called  irritable  heart  of  soldiers  so  well  described  by  Da 
Costa  (Medical  Diagnosis,  page  405)  is  characterized  by  habitual  rapidity 
complicated  by  paroxysms  of  palpitation  and  precordial  pain  brought 
on  by  exercise,  with  frequent  attacks  of  headache,  dizziness,  and  cuta- 
neous hyperesthesia. 

With  the  paroxysmal  form  of  tachycardia  in  addition  to  the  palpable 
and  visible  rapidity  of  the  cardiac  impulse,  physical  exploration  may 
elicit  signs  of  pulmonary  congestion.  In  irritable  heart,  Da  Costa  says 
the  action  is  rapid,  often  irregular  and  rather  abrupt  and  jerky,  the  first 
sound  short  and  sharp  like  the  second,  but  sometimes  very  faint. 

Prognosis. — In  severe  paroxysmal  cases,  the  prognosis  is  uncertain, 
varying  with  the  persistence,  frequency  and  severity  of  the  attacks. 

Treatment  is  that  suited  to  functional  disease. 


250  CARDIAC  AND  ARTERIAL  DISEASES. 


BRADYCARDIA. 

Bradycardia  or  abnormal  slowness  of  the  pulse  though  often  seen 
in  slight  degree,  is  much  rarer  as  a  well-marked  characteristic  than 
rapid  pulse.  The  frequency  may  fall  as  low  as  seventeen  beats  per 
minute  (Balfour,  Edinburgh  Medical  Journal,  1890).  In  one  variety  both 
heart  and  pulse  beat  alike,  in  another  the  pulsations  of  the  heart  while 
normal  in  frequency  at  the  apex  are  so  weak  that  all  are  not  felt  at  the 
wrist.  Frentiss'  classification  of  the  causes  of  slow  pulse  is  as  follows: 
disease  or  injury  of  the  nerve  centre  causing  paralysis  of  the  sympa- 
thetic nerve  or  irritation  of  the  pneumogastric  nerve;  disease  or  injury 
to  the  trunk  of  the  vagus,  increasing  its  irritability;  disease  or  injury 
paralyzing  the  sympathetic;  disease  of  the  cardiac  ganglia;  disease  of 
the  heart  muscles;  action  of  poisons  upon  the  nerve  centre  or  endings 
[International  Medical  Annual,  1801).  I  have  seen  a  few  cases  that 
seemed  the  direct  result  of  prolonged  severe  pain.  When  well  marked, 
it  is  usually  an  unfavorable  sign,  owing  to  the  tendency  to  pseudo-epi- 
leptic and  pseudo-apoplectic  attacks.  Death  may  occur  during  these 
seizures  or  from  asthenia.     It  may  be  a  symptom  of  fatty  heart. 

Treatment  must  aim  at  general  nervous  and  cardiac  stimulation. 


ANGINA   PECTORIS. 

Angina  pectoris  is  a  term  applied  to  attacks  of  severe  paroxysmal 
cardiac  pain,  associated  with  a  sense  of  impending  death  and  minor 
phenomena  commonly  symptomatic  of  serious  organic  lesions.  A  dis- 
tinction is  to  be  drawn  clinically  and  etiologically  between  true  angina 
pectoris  of  organic  origin  and  pseudo-angina  or  hysterical  angina  de- 
pendent upon  diathetic  or  toxic  influences.  True  angina  most  fre- 
quently attacks  men  of  advanced  years,  but  the  false  variety  is  commonly 
found  in  comparatively  young  neurotic  women. 

Etiology. — True  angina  pectoris  seems  in  most  cases  to  depend 
upon  arterio-sclerosis  and  other  diseases  of  the  coronary  arteries  tending 
to  their  contraction  or  obliteration,  and  consequent  deficient  nutrition 
of  the  heart.  According  to  Liegeois  {Bulletin  medicate  des  Vosges,  1888) 
three-fourths  of  all  cases  may  be  assigned  to  sclerosis  or  atheroma  of  the 
coronary  arteries  or  aorta.  Not  infrequently  the  affection  appears  to  de- 
pend upon  cardiac  dilatation, valvular  disease,  fatty  and  other  degenerative 
changes,  aneurism,  or  pericarditis,  any  of  which  may  disturb  the  circula- 
tion through  the  coronary  arteries.  Douglas  Powell  believes  vasomotor 
disturbance  an  essential  factor  in  the  majority  of  cases  of  angina  pectoris 
(British  Medical  Journal,  1891).  Sometimes  no  cause  for  the  di3ease 
can  be  discovered.  Among  possible  causes  may  be  mentioned  organic 
affections,  such  as  cancer  involving  the  pneumo-gastric  or  cardiac  and 


ANGINA  PECTORIS.  251 

thoracic  plexus  of  the  sympathetic  {Lyon  Medicale,  1888),  chronic  neuritis 
and  pigmentary  and  granular  degeneration  of  nerve  cells  (La  Semaine 
Medicale,  March,  1890).  The  immediate  cause  of  the  paroxysm  may 
be  embolism  of  the  coronary  artery,  but  it  is  usually  some  mental  or 
physical  exertion,  sexual  derangement,  error  of  diet,  or  excess,  influenc- 
ing the  vasomotor  mechanism.  Occasionally  the  gouty  and  rheumatic 
diatheses,  by  vitiating  the  blood  supply,  are  undoubted  etiological  fac- 
tors both  in  producing  the  primary  disease  and  in  favoring  the  parox- 
ysm. Pseudo-angina  may  be  clue  to  reflex  causes  or  to  direct  central 
irritation.  The  former  are  commonly  of  gastric  or  hepatic  origin,  such 
as  indigestion,  gastric  catarrh,  flatulence,  or  the  presence  of  gall  stones; 
the  latter  include  cerebral  and  spinal  neurasthenia  and  locomotor  ataxia. 

Symptomatology. — The  most  characteristic  symptoms  of  true  angina 
pectoris  are  agonizing  sternal  or  praecordial  pain  probably  caused  in  most 
cases  by  over-distention  of  the  heart,  with  a  peculiar  fear  of  impending 
death.  This  pain  usually  radiates  to  the  left  shoulder  and  down  the 
arm,  often  stopping  at  the  elbow,  but  frequently  extending  to  the  ring 
and  little  finger.  It  is  often  severe  up  the  side  of  the  neck  and  behind 
the  ear.  It  sometimes  extends  to  the  right  side  and  may  occasionally 
be  felt  in  the  thighs.  The  pain  has  been  variously  likened  to  a  stab,  a 
thrust  with  a  red-hot  iron,  a  sensation  of  suffocation,  or  grip  of  an  icy 
hand.  Pallor  and  fear  are  depicted  on  the  countenance,  and  respira- 
tion is  frequently  interrupted  as  though  the  sufferer  had  forgotten  to 
breathe.  The  pulse  is  usually,  though  not  always,  feeble  and  irregular 
or  intermittent.  The  duration  of  acute  attacks  is  usually  from  half  an 
hour  to  two  or  even  three  hours,  and  they  not  infrequently  terminate  in 
syncope  or  death.  If  the  patient  survives  the  first  attack  others  are 
liable  to  occur  at  irregular  intervals,  at  first  far  apart,  but  ere  long 
nearer  together  until  one  finally  proves  fatal.  Attacks  of  pseudo-angina 
are  generally  of  longer  duration  but  of  less  severity. 

No  characteristic  signs  accompany  either  variety  of  the  affection,  but 
valvular  disease,  fatty  degeneration,  or  dilatation  of  the  heart  is  com- 
monly present  in  true  angina. 

Diagnosis. — Angina  pectoris  proper  may  be  confused  with  the 
hysterical  form,  or,  if  mild,  may  possibly  be  mistaken  for  intercostal 
neuralgia,  acute  pleurisy,  or  myalgia.  It  may  be  distinguished  from 
pseudo-angina  pectoris  by  the  following  points: 

True  angina  pectoris.  Hysterical  or  pseudo-angina 

pectoris. 

History. 

Usually  in  men  over  forty;  cardiac  Oftenest  in  women  ;  any  age ;  neu- 

lesions.  especially   arterio-sclerosis  of  ralgic  diathesis,  but  no  cardiac  lesions, 

the  coronary  arteries   and   fatty   de-  Attacks  spontaneous  ;  usually  at  night, 
generation.     Attacks  caused  by  exer- 
tion anv  time  of  day. 


252  CARDIAC  AND  ARTERIAL    DISEASES. 


True  angina  pectoris.  Hysterical  or  pseudo-angina 

,    pectoris. 

Symptoms. 

Pain  very  severe  and  of  short  dura-  Pain  less  severe  and  of  longer  dura- 

tion, tion. 

Comparative  silence  and  immobility;  Comparative  agitation  and  activity; 

often  speedily  fatal.  Not  relieved  by  seldom  if  ever  fatal.  Relieved  by  anti- 
anti-neuralgic  remedies.  neuralgic  medication. 

Signs. 
Murmurs  and  enlargement  frequent.  No  organic  disease. 

It  may  be  differentiated  from  intercostal  neuralgia  by  the  history  and 
presence  of  the  characteristic  painful  points  in  the  latter  disease.  In 
myalgia,  the  character  and  seat  of  the  pain,  the  tenderness  of  the  mus- 
cles, and  other  symptoms  are  sufficiently  diagnostic.  The  pain  of  acute 
pleurisy  is  attended  by  cough,  pyrexia,  and  distinct  physical  signs  not 
present  in  angina. 

Prognosis. — The  first  attack  of  angina  pectoris  is  often  fatal  within 
two  or  three  hours,  and  sometimes  a  sudden  sharp  pain  is  the  only  warn- 
ing of  instant  death.  More  frequently  the  patient  survives  the  first 
paroxysm,  but  after  a  few  months  dies  in  the  second  or  third  attack. 
Sometimes  patients  live  for  many  years  subject  to  occasional  attacks 
which  gradually  become  more  and  more  frequent  until  finally  resulting 
in  death.  A  considerable  number,  however,  recover  under  appropriate 
treatment  or  at  least  live  many  years  with  but  few  and  light  attacks  of 
the  cardiac  pain.  In  pseudo-angina,  the  prognosis  is  favorable  provid- 
ing its  cause  can  be  removed. 

Treatment. — For  the  paroxysms,  alcoholic  stimulants,  opiates,  or 
inhalations  of  amyl  nitrate  tti^v.  to  vi.,  or  of  chloroform  are  most  efficient. 
Chloroform,  though  apparently  a  dangerous  remedy,  has  proved  harm- 
less, prompt,  and  efficient  when  administered  as  recommended  by  G.  W. 
Balfour,  of  Edinburgh  (Clinical  Lectures  on  Diseases  of  the  Heart, 
1STG).  Half  a  drachm  is  poured  upon  a  sponge  at  the  bottom  of  a  wide- 
mouthed  bottle,  from  which  the  patient  may  breathe  ad  libitum  until 
relieved.  The  patient  drops  the  bottle  as  soon  as  he  becomes  partially 
unconscious,  and  it  rolls  away.  Nitroglycerin  has  been  recommended 
foi  the  cure  of  angina  pectoris,  and  from  the  published  reports  it  aj> 
pears  that  numerous  cases  have  been  benefited  by  it.  I  have  found  it 
of  much  value  in  stimulating  the  heart  and  relieving  the  painful  parox- 
ysm, but  I  have  not  witnessed  curative  results.  It  is  administered 
either  in  pill,  tablet  triturate,  or  solution.  The  dose  administered  to 
relieve  the  paroxysm  is  ordinarily  gr.  jfa,  which  may  be  repeated  once 
in  twenty  minutes  until  three  or  four  doses  have  been  taken  or  relief  is 
obtained,    unless   its  physiological   effects  are   too  strongly   developed. 


AXixIXA   PECTORIS.  253 

AYhen  the  susceptibility  of  the  patient  to  the  remedy  has  been  ascer- 
tained, doses  two  or  three  times  larger  may  sometimes  be  given.  To 
prevent  recurrence  of  the  attack,  it  may  be  given  three  times  daily,  at 
first  in  doses  of  gr.  j-^-,  but  these  may  be  increased  to  five,  ten,  or  even 
fifteen  times  as  much,  providing  that  it  does  not  cause  severe  headache, 
giddiness,  or  overpowering  somnolence.  During  the  intervals  between 
the  attacks  of  angina,  the  same  hygienic  rules  should  be  observed  as  in 
valvular  disease.  Arsenious  acid  should  be  given  in  moderate  doses, 
with  or  without  iron,  strychnine,  and  digitalis,  acccrding  to  special 
indications. 

Huchard  claims  that  large  doses  of  potassium  iodide  (grs.  xl.  to  1. 
daily)  continued  several  years  with  intervals  of  eight  or  ten  days  each 
month  during  which  it  is  suspended,  will  cure  angina  pectoris  and  arterio- 
sclerosis of  the  heart  (Gazette  des  Eopitauz,  1890).  The  remedy  is  cer- 
tainly very  efficient  in  relieving  the  pains  of  aneurism  and  sometimes  in 
relieving  cardiac  pain.  In  pseudo-angina,  the  cause  must  be  ascertained 
and  removed  if  possible.  Remedies  usually  should  be  directed  to  the 
relief  of  rheumatism,  anaemia,  or  debility,  or,  most  important,  to  the 
correction  of  indigestion. 


CHAPTER  XV. 

CAEDIAC   AND   ARTERIAL  DISEASES.— OntitM*a 

AORTITIS. 

The  symptoms  ascribed  to  acute  exudative  inflammation  of  the  aorta 
have  been  described  by  Frank,  Bizot,  and  others;  but  as  stated  by  R. 
Douglass  Powell,  the  disease  as  a  primary  affection  is  of  very  doubtful, 
if  not  impossible,  occurrence.  We  need  not  attempt  to  describe  any  of 
the  signs  or  symptoms  it  might  possibly  occasion. 

ATHEROMA  OF  THE  AORTA. 

Synonyms. — Aortic  endarteritis  ;  atheromatous  degeneration  of  the 
aorta. 

Atheroma  of  the  aorta  may  be  defined  as  a  degeneration  of  the  coats 
of  the  aorta,  consisting  of  an  irregular  thickening  and  softening  of  its 
walls,  especially  of  its  inner  coat. 

It  seldom  occurs  before  the  forty-fifth  year  of  age. 

Anatomical  and  Pathological  Characteristics. — The  disease 
consists  of  thickening  and  fatty  degeneration,  usually  followed  by  cal- 
careous infiltration  and  occasionally  by  ulceration.  It  is  primarily  con- 
fined to  the  intima,  but  not  infrequently  involves  the  muscular  coat.  It 
begins  with  inflammation,  occurring  in  scattered  patches,  which  have 
the  milky  opacity  characteristic  of  the  first  stage  of  acute  endocarditis  ; 
later  these  become  yellow  from  loXtj  change.  These  areas  may  coalesce 
to  some  extent,  and  deposits  of  lime  salts  commonly  take  place,  giving 
the  surface  a  scaly  or  nodular  appearance  and  chalky  hardness.  Ulcera- 
tion occasionally  results  from  rapid  central  softening  of  the  patch  and 
discharge  of  the  debris.  Microscopically,  the  thickened  intima  early 
shows  round  and  spindle  cell  infiltration  and  more  or  less  increase  of 
fibrous  elements,  but  no  blood-vessels.  Later  the  spots  of  softening  are 
found  to  contain  oil  globules,  crystals  of  cholesterin,  and  a  granular 
debris.  These  processes  result  at  first  in  thickening  of  the  arterial  wall, 
finally  weakening,  loss  of  elasticity,  dilatation,  and  in  some  cases  aneu- 
rism. 

The  affection  is  usually  limited  to  the  initial  portion  of  the  blood- 
vessel ;  indeed  clinical  evidence  of  its  existence  beyond  the  transverse 
portion  of  the  arch  is  very  rare. 

Etiology. — The  chief  causes  are:  gout,  rheumatism,  syphilis,  chronic 


ATHEROMA    OF  THE  AORTA.  255 

nephritis,  high  living  with  insufficient  exercise,  and  the  excessive  rise  of 
alcoholics.  It  sometimes  results  from  undue  strain  of  the  artery,  as  in 
excessive  muscular  efforts. 

Symptomatology. — The  symptoms  of  atheroma  of  the  aorta  are 
always  obscure,  and  its  physical  signs,  in  many  cases,  are  far  from  posi- 
tive. Among  the  most  prominent  symptoms  and  signs,  we  observe  at- 
tacks of  palpitation  or  anginal  pain  and  dyspnoea,  which  are  usually 
brought  on  by  exercise,  but  may  occur  independent  of  exertion.  Dur- 
ing these  attacks  the  pulse  is  commonly  very  weak.  Signs  of  gen- 
eral atheroma  may  often  be  detected  in  the  abnormal  rigidity  of  the 
temporal,  radial,  and  brachial  arteries. 

By  inspection  and  palpation,  when  dilatation  has  taken  place,  feeble 
pulsation  may  be  seen  or  felt  in  the  second  intercostal  space  close  to 
the  sternum,  on  the  right  side. 

Upon  percussion,  there  is  found  a  somewhat  increased  area  of  dulness 
over  the  ascending  or  transverse  portion  of  the  aorta. 

On  auscultation  early  in  the  disease,  there  may  be  some  evidence  of 
hypertrophy  of  the  left  ventricle,  as  indicated  by  an  increased  impulse 
and  muffling  of  the  first  sound  of  the  heart.  These  signs,  however,  are 
not  characteristic,  as  they  might  arise  from  emphysema  or  other  cause 
of  obstructed  circulation. 

"With  the  advent  of  dilatation,  the  first  sound  of  the  heart  becomes 
more  indistinct,  while  there  is  accentuation  of  the  second  sound  over  the 
aortic  valves,  thought  by  some  to  be  diagnostic  of  dilatation  of  the  aorta. 
A  short  murmur  is  usually  heard  over  the  aorta,  immediately  after  the 
systole  of  the  ventricles,  especially  when  the  action  of  the  heart  is  rapid. 
As  dilatation  progresses,  the  bruit  becomes  more  distinct.  It  is  some- 
times rough  in  character,  and  may  be  associated  with  a  purring  tremor. 

The  second  sound  may  be  partially  supplanted  by  a  faint  diastolic 
murmur,  due  to  dilatation  at  the  origin  of  the  artery,  which  renders 
the  semilunar  valves  incompetent  to  close  the  orifice,  and  allows  regurgi- 
tation into  the  ventricles. 

When  the  heart  is  beating  slowly  and  regularly,  both  the  first  and 
second  sounds  may  be  accentuated  over  the  upper  part  of  the  sternum, 
and  the  systole  of  the  heart  may  be  attended  by  a  slight  impulse  in  the 
aortic  area;  but  this  latter  sign,  to  be  of  value,  must  be  obtained  when 
the  patient  is  perfectly  quiet. 

Later  in  the  disease,  dyspnoea  becomes  marked,  the  attacks  of  angina 
are  more  frequent  and  persistent,  and  the  symptoms  of  embolism,  such 
as  hemiplegia,  rigors,  hematuria,  superficial  hemorrhages,  or  gangrene, 
may  make  their  appearance;  or  the  formation  of  a  sacculated  aneurism 
from  the  affected  portion  of  the  artery  may  be  indicated  by  the  sudden 
occurrence  of  pain,  dyspnoea,  and  faintness.  Finally,  sudden  death  may 
result  from  heart  failure  or  from  rupture  of  the  aorta. 

Diagnosis. — The  principal  symptoms  and  signs  of  atheroma  of  the 


25G  CARDIAC  AND  ARTE  RIAL  DISEASES. 

aorta  are:  palpitation,  pain,  and  dyspnoea,  with  rigidity  of  the  superficial 
arteries,  muffling  of  the  first  sound  of  the  heart,  and  accentuation  of  the 
second,  over  the  aortic  valves.  The  first  heart  sound  is  usually  followed 
by  a  more  or  less  distinct  systolic  murmur.  Sometimes  there  is  a  dias- 
tolic murmur  in  the  region  of  the  ascending  or  transverse  portion  of  the 
arch  of  the  aorta,  with  slight  increase  in  the  area  of  dulness  during  the 
later  stages.  The  affection  might  be  mistaken  for  simple  disease  of  the 
aortic  valves,  or  inorganic  disease  of  the  heart,  with  ana?mic  murmurs. 

Though  it  may  cause  many  of  the  symptoms  and  signs  of  atheroma, 
disease  of  tin1  aortic  valves  is  not  attended  by  a  rigid  condition  of  the 
superficial  arteries,  or  the  peculiar  neuralgic  pains  which  usually  attend 
atheroma,  and  it  does  not  cause  accentuation  of  the  second  sound  at  the 
aortic  valves  or  an  increased  area  of  dulness  at  the  base. 

When  anaemic  murmurs  are  associated  with  functional  disease  of  the 
heart,  they  are  not  attended  by  rigidity  of  the  superficial  arteries,  by 
the  peculiarly  distinct  accentuation  of  the  second  sound,  by  the  systolic 
shock,  by  the  diastolic  bruit,  or  by  increased  area  of  dulness. 

Treatment. — Morphine,  nitroglycerin,  or  other  anti-spasmodic  rem- 
edies are  indicated  during  the  attacks  of  dyspnoea.  Potassium  iodide 
continued  for  months,  with  short  intermissions,  is  sometimes  useful. 
Excessive  exertion  must  be  avoided. 

AORTIC   OR  THORACIC   ANEURISM. 

An  aneurism  is  a  sac  the  cavity  of  which  communicates  with  the 
lumen  of  the  artery. 

Anatomical  and  Pathological  Characteristics. — Aneurism  may 
exist  as  a  fusiform  dilatation  of  the  artery,  but  usually,  when  well 
marked,  it  is  saccular,  forming  a  pouch-like  projection  from  the  vessel. 
The  wall  of  the  aneurism  may  be  composed  of  all  the  coats  of  the  vessel, 
though  commonly  the  muscular  tunic  is  wanting.  Earely,  the  walls  are 
formed  by  a  condensation  of  the  surrounding  tissues  into  which  the 
artery  has  ruptured,  called  diffuse  aneurism.  If  the  blood  effects  sepa- 
ration of  the  arterial  coats,  a  dissecting  aneurism  is  formed.  The  cavity 
is  generally  lined  with  concentrically  stratified  blood  clots  of  varying 
age,  thickness,  and  consistence,  which  are  occasionally  calcified.  As 
the  aneurism  enlarges,  pressure  upon  adjacent  respiratory,  circula- 
tory, nervous,  or  bony  structures  produces  characteristic  symptoms 
and  may  eventually  effect  their  destruction.  The  walls  of  the  sac  gen- 
erally undergo  atheromatous  degeneration,  and  may  rupture  into  the 
pleural  cavity,  lungs,  bronchi,  trachea,  pericardium,  oesophagus,  or 
through  the  chest  wall. 

Etiology. — Aneurism  occurs  generally  in  adults,  oftenest  between 
the  ages  of  forty  and  fifty.  Occupations  which  subject  the  individual 
to  exposure  and  severe  bodily  strain  favor  its  development.     Atheroma 


ANEURISM  OF  THE  DESCENDING  AORTA.  257 

of  the  walls  of  the  artery  is  the  chief  predisposing  cause,  whether  due  to 
syphilis,  chronic  nephritis,  gout,  rheumatism,  chronic  alcoholism,  lead 
or  mercurial  poisoning,  or  to  several  of  these  combined.  The  immediate 
cause  may  be  sudden  strain,  a  blow,  fall  or  wound,  or  continued  excesses. 

ANEURISM    OF   THE    SINUSES    OF    VALSALVA. 

Aneurism  of  the  sinuses  of  Valsalva  is  usually  so  small  as  to  give 
rise  to  no  peculiar  symptoms  or  signs,  but  the  indications  of  athe- 
romatous degeneration,  with  a  pulmonary  systolic  or  diastolic  mur- 
mur due  to  pressure  of  the  aneurism  on  the  origin  of  the  pulmonary 
artery,  might  lead  us  to  susjDect  the  true  nature  of  the  lesion.  The  diag- 
nosis can  rarely,  if  ever,  be  made  with  certainty,  as  the  tumor  lies  en- 
veloped in  the  pericardium,  so  close  to  the  heart  that  it  is  almost  impos- 
sible to  distinguish  between  the  murmurs  which  it  produces  and  those 
of  valvular  origin. 

ANEURISM    OF    THE    ARCH    OF    THE    AORTA. 

Aneurism  of  the  arch  of  the  aorta  consists  of  preternatural  dilatation 
of  the  artery,  Avhich  may  be  general  involving  the  whole  circumference 
in  a  fusiform,  cylindrical  or  globular  swelling;  or  sacculated,  forming  a 
pouch-like  projection  from  one  side  of  the  artery. 

Sacculated  aneurisms  are  usually  globular  at  first,  but  may  subse- 
quently acquire  different  forms,  especially  the  conical. 

Aneurisms  may  occur  in  the  ascending,  transverse,  or  descending 
portion  of  the  arch  of  the  aorta.  About  one-half  have  their  origin  in 
the  ascending  portion;  a  few  involve  both  the  ascending  and  the  trans- 
verse, or  simply  the  transverse  portion  of  the  arch.  Nearly  one-fourth 
arise  from  the  descending  arch,  and  about  the  same  number  from  that 
portion  of  the  aorta  between  the  arch  and  the  diaphragm. 

ANEURISM    OF    THE    DESCENDING    AORTA. 

Aneurism  of  the  descending  aorta  ultimately  causes  a  pulsating  tumor 
behind,  at  the  left  of  the  spinal  column,  between  the  third  dorsal  verte- 
bra and  the  point  at  which  the  aorta  perforates  the  diaphragm.  Erosion 
of  the  vertebras,  with  consequent  curvature  of  the  spine,  is  usually  pro- 
duced by  pressure.  Subsequent  compression  of  the  spinal  cord  may 
cause  paraplegia.  The  tumor,  if  large,  usually  displaces  the  heart  for- 
ward and  to  the  right.  In  exceptional  instances,  aneurisms  of  this  por- 
tion of  the  aorta  may  be  detected  upon  the  right  side  of  the  spinal 
column.  The  bruit,  in  an  aneurism  of  the  descending  aorta,  may  be 
distinguished  from  a  mitral  regurgitant  murmur,  frequently  heard  in  a 
similar  position,  by  the  fact  that  the  aneurismal  murmur  is  heard  not 
only  between  the  fifth  and  the  eighth  dorsal  vertebras,  but  also  above 
and  below  this  position.  The  mitral  regurgitant  murmur  is  not  heard 
i7 


258  CARDIAC  AND  ARTERIAL  DISEASES. 

distinctly  above  the  lower  border  of  the  fifth  or  below  the  upper  border 
of  the  eighth  vertebra. 

Symptomatology.— Tumors  of  this  character  may  sometimes  be 
diagnosticated  from  the  symptoms,  when  they  cannot  be  located  by  the 
physical  signs.  The  more  prominent  symptoms,  though  not  indi- 
vidually characteristic,  may  be  sufficient  for  the  purpose  of  diagnosis 
when  grouped  together,  and  are  of  great  value  when  taken  in  connection 
with  the  physical  signs.  Enumerated  nearly  in  the  order  of  their  im- 
portance, they  are:  pain,  dyspnoea,  palpitation,  dysphagia,  headache,  and 
disordered  vision. 

The  pain  in  aortic  aneurism  is  persistent,  of  a  peculiar  wearing,  ach- 
ing, or  burning  character,  and  is  referred  to  the  region  of  the  tumor. 
Frequently  there  are  neuralgic  exacerbations,  with  pain  radiating  in  the 
course  of  contiguous  nerves. 

Dyspnoea  of  varying  degree  is  generally  present,  and  is  usually  ag- 
gravated by  much  slighter  causes  than  those  which  would  occasion 
the  same  symptom  in  other  varieties  of  intrathoracic  tumors.  It  fre- 
quently occurs  in  severe  paroxysms,  which  may  be  due  to  one  or  more 
causes.  Ordinarily,  such  attacks  are  ascribed  to  spasm  of  the  glottis, 
resulting  from  irritation  of  one  or  both  of  the  recurrent  laryngeal  nerves. 
More  probably  they  are  due  to  paralysis  of  the  abductor  muscles  of  the 
glottis  which  are  supplied  by  these  nerves,  with  consequent  falling  to- 
gether of  the  vocal  cords,  and  obstruction  of  the  glottis  during  inspira- 
tion. 

The  exacerbations  of  this  symptom  are  due  in  some  instances  to  a 
collection  of  mucus  at  the  glottis;  in  others  to  the  varying  pressure  of 
the  aneurism  upon  the  nerve  which,  at  one  time,  completely  suspends 
its  function,  at  another  interferes  with  it  but  slightly.  The  voice  is 
also  modified  more  or  less  by  the  same  cause,  and  may  be  entirely  lost. 

Dyspnoea  is  sometimes  dependent  upon  narrowing  of  the  trachea 
or  of  the  bronchi  from  pressure  of  the  aneurism.  In  such  instances, 
the  paroxysms  are  probably  due  to  a  collection  of  mucus  which  the 
patient  may  be  unable  to  expectorate  at  the  point  of  stricture. 

Palpitation  of  the  heart  is  generally  produced  by  slight  exertion;  it 
may  be  due  to  irritation  of  the  sympathetic  nerve  or  paralysis  of  the 
vagus  from  pressure. 

Dysphagia,  due  to  pressure  upon  the  oesophagus,  is  often  present, 
though  it  is  a  less  frequent  symptom  with  aneurismal  than  with  other 
tumors. 

Headache,  due  to  interference  with  the  return  of  blood  to  the  heart, 
is  not  uncommon. 

Disordered  vision  is  due  to  pressure  upon  the  sympathetic  nerve, 
and  consequent  interference  with  the  action  of  the  iris.  Ordinarily  the 
pupil  upon  the  affected  side  is  strongly  contracted,  but  in  rare  instances, 
from  complete  paralysis  of  its  sympathetic  nerve,  it  may  be  dilated. 


ANEURISM  OF  THE  DESCENDING  AORTA.  259 

Haemoptysis,  to  a  slight  degree,  is  an  occasional  symptom  due  to  con- 
gestion of  the  mucous  membrane.  Copious  haemoptysis  frequently  oc- 
curs at  the  close  of  the  disease,  when  the  aneurism  ruptures  into  the  air 
passages. 

The  essential  signs  are :  a  pulsating  tumor  in  the  region  of  the  aorta, 
with  systolic  and  diastolic  shock  and  sometimes  bruits. 

Upon  inspection,  we  often  observe  marked  lividity  of  the  face,  neck, 
and  upper  extremities;  with  turgescence  and  a  varicose  condition  of  the 
veins,  and  perhaps  oedema,  due  to  obstruction  in  the  return  of  blood  to 
the  heart  from  pressure  of  the  aneurism  upon  one  of  the  venae  innom- 
inatae  or  the  descending  vena  cava.  Occasionally  a  thick  fleshy  collar  is 
found  about  the  base  of  the  neck,  due  to  capillary  turgescence. 

(Edema  and  turgescence  are  ordinarily  limited  to  one  side,  and  are 
caused  by  pressure  on  one  of  the  venae  innominatae.  If  the  pressure  is 
upon  the  descending  vena  cava,  which  is  most  likely  to  occur  with  an 
aneurism  of  the  ascending  arch,  these  signs  will  be  found  upon  both 
sides. 

The  surface  of  the  chest  is  seen  to  have  a  marbled  appearance,  caused 
by  the  prominence  and  blueness  of  the  veins. 

A  tumor  may  usually  be  observed  in  the  course  of  the  aorta,  the 
position  of  which  will  indicate  the  part  of  the  blood-vessel  affected. 

When  an  aneurism  originates  in  the  sinuses  of  Valsalva  it  causes  no 
external  tumor.  When  in  the  ascending  portion  of  the  aorta,  if  bulging 
occurs,  it  will  be  seen  in  the  second  intercostal  space  at  the  right  side  of 
the  sternum;  but  if  large,  it  may  extend  far  into  the  infraclavicular 
region,  and  even  to  the  mammary. 

Aneurism  of  the  transverse  portion  of  the  arch  causes  a  tumor  at  the 
upper  part  of  the  sternum. 

When  the  descending  arch  is  involved  the  tumor  generally  presents 
posteriorly  at  the  left  of  the  spinal  column. 

Exceptional. — In  exceptional  cases,  an  aneurism  of  the  descending  arch  of 
the  aorta  may  be  seen  in  front,  and  in  very  rare  instances  it  may  be  found  at 
the  right  of  the  spinal  column. 

Aneurisms  of  the  descending  aorta  present  posteriorly  below  the 
fourth  dorsal  vertebra  at  the  left  of  the  spine.  Very  rarely  they  are 
seen  at  the  right  of  the  spinal  column. 

These  tumors  vary  in  size  from  a  slight  prominence  to  one  as  large 
as  a  child's  head.  The  absence  of  a  tumor  does  not  necessarily  prove 
that  no  aneurism  exists ;  for,  while  the  aneurism  is  small,  it  may  not 
press  upon  the  chest  walls,  and  even  when  of  considerable  size  the  posi- 
tion may  be  such  that  no  bulging  is  occasioned.  The  larger  of  these 
tumors  are  generally  conical  in  form,  and  present  very  much  the  appear- 
ance of  an  immense  boil,  covered  by  thin  glazed  integument. 


260  CARDIAC  AND  ARTERIAL  DISEASES. 

If  pulsation  of  the  tumor  be  observed,  it  will  occur  rhythmically  with 
the  apex  beat  of  the  heart.  Pulsation,  which  cannot  otherwise  be  seen, 
may  sometimes  be  detected  by  bringing  the  eye  to  the  level  of  the  sur- 
face of  the  chest,  as  in  standing  behind  the  patient  and  looking  down 
over  his  shoulders.  "No  pulsation  will  be  visible  if  the  aneurismal  sac  is 
occupied  by  fibrin  or  coagulated  blood. 

If  the  tumor  press  on  one  of  the  main  bronchi  the  respiratory  move- 
ments on  the  corresponding  side  will  be  diminished  or  absent. 

By  palpation  we  may  frequently  detect  a  tumor,  the  impulse  of  which 
cannot  be  seen;  we  can  ascertain  the  condition  of  the  chest  walls, 
whether  there  be  perforation  of  the  costal  cartilages,  sternum,  or  ribs, 
and  may  usually  determine  whether  the  contents  of  the  tumor  are  fluid 
or  solid.  The  character  of  the  pulsation  is  expansile,  that  is,  alike  in 
every  direction,  and  not  simply  lifting  as  is  the  case  when  a  solid  tumor 
rests  upon  an  artery. 

The  most  valuable  sign  obtained  by  this  method  is  the  detection  of 
two  pulsating  points,  as  though  there  were  two  hearts,  one  beating  in 
the  normal  position  in  the  fifth  interspace,  and  the  other  above  the  third 
rib. 

If  the  aneurism  is  so  small  as  to  escape  observation  by  ordinary  palpation  it 
may  sometimes  be  detected  by  pressing-  firmly  with  one  hand  over  the  aorta  in 
front,  and  with  the  other  posteriorly. 

The  impulse  obtained  over  an  aneurism  may  be  systolic,  occurring 
with  the  contraction  of  the  ventricles;  or  it  may  be  both  systolic  and 
diastolic.  The  latter,  produced  by  contraction  of  the  artery,  is  usually 
slight,  but  occasionally  quite  forcible.    When  found,  it  is  a  valuable  sign. 

Frequently  these  tumors  give  rise  to  a  peculiar  thrill,  similar  to  the 
purring  tremor;  sometimes  very  early  in  the  course  of  an  aneurism  of 
the  transverse  arch,  an  impulse  or  a  thrill  may  be  felt  by  pressing  the 
finger  downward  behind  the  suprasternal  notch. 

Valuable  information  may  be  obtained  in  some  cases  from  the  pulse, 
or  from  sphygmographic  tracings  (Fig.  42).  If  the  aneurism  press 
upon  the  arteria  innominata,  or  upon  either  of  the  subclavian 
arteries,  or  if  either  of  these  vessels  is  obstructed  by  a  coagulum,  the 
radial  pulse  will  be  feebler  upon  the  corresponding  side.  The  carotids 
are  sometimes  similarly  affected.  If  atheromatous  degeneration  of  the 
arteries  be  general,  the  superficial  arteries,  especially  the  radial  and  tem- 
poral, will  be  found  rigid  and  non-elastic. 

Alterations  in  the  movements  of  the  chest  walls  and  in  the  vocal 
fremitus  are  also  to  be  sought  by  palpation.  Pressure  on  the  air  pas- 
sages will  diminish  the  respiratory  movements,  and  cause  local  or  gen- 
eral diminution  or  absence  of  the  vocal  fremitus,  according  as  a  bronchus 
or  the  trachea  is  obstructed  or  the  lung  itself  compressed. 

Percussion  must  be  performed  gently,  especially  over  large  aneurisms, 
as  a  forcible  stroke  might  possibly  rupture  the  weakened  blood-vessel. 


ANEURISM  OF  THE  DESCENDING  AORTA.  261 

Upon  gentle  percussion,  the  extent  of  dulness  will  not  correspond  to  the 
size  of  the  tumor,  because  of  the  overlapping  borders  of  the  lungs;  but 
by  a  more  forcible  stroke,  or  by  auscultatory  percussion,  we  may  deter- 
mine the  limits  accurately. 

The  area  of  abnormal  dulness  is  usually  much  smaller  than  in  other 
tumors,  causing  symptoms  of  equal  gravity. 

The  sense  of  resistance  felt  upon  percussion  is  a  valuable  sign  in  dis- 
tinguishing between  aneurisms  and  other  intrathoracic  tumors.  Over 
a  tumor  filled  with  fluid,  the  resistance  is  much  less  than  over  a  solid 
growth  or  over  an  aneurism  filled  with  fibrinous  deposits. 

If  the  aneurism  present  posteriorly,  dulness  will  be  obtained  in  the 
interscapular  region.  If  it  press  upon  a  main  bronchus,  or  upon  one 
lung,  causing  collapse  or  congestion  of  this  organ,  dulness  will  be  found 
over  the  corresponding  side. 

In  auscultation,  upon  listening  over  an  aneurism,  we  first  notice  an 
impulse  or  shock  with  each  contraction  of  the  heart.  This  is  frequently 
followed  immediately  by  a  second  or  diastolic  shock,  due  to  contraction 
of  the  arteries.  The  impulse  is  usually  attended  by  one  or  two  sounds 
which  consist  mainly  of  the  transmitted  heart  sounds,  but  are  in  part 
produced  by  dilatation  and  contraction  of  the  artery. 

These  sounds  may  be  associated  with  or  supplanted  by  murmurs 
somewhat  similar  in  character  to  endocardial  murmurs.  However,  they 
are  ordinarily  less  intense,  though  they  may  be  even  louder  than  the 
loudest  heart  murmurs.  They  are  usually  harsh  in  quality,  and  are  not 
transmitted  into  the  same  regions  as  endocardial  murmurs.  Sometimes 
neither  sounds  nor  murmurs  can  be  detected  over  the  aneurism. 

If  the  tumor  press  upon  a  main  bronchus,  the  respiratory  murmur 
will  be  diminished  or  absent  upon  the  corresponding  side,  while  on  the 
other  it  will  be  exaggerated.  In  these  instances  a  forced  inspiration 
will  sometimes  distend  the  lung,  and  bring  out  the  respiratory  murmur 
where  it  could  not  be  heard  during  ordinary  breathing.  Vocal  resonance 
will  be  diminished  or  absent  over  the  obstructed  lung,  and  absent  over 
the  aneurism.  If  the  lung  be  condensed  by  pressure,  broncho- vesicular 
respiration  may  be  heard. 

If  the  tumor  press  upon  the  recurrent  laryngeal  nerve,  so  as  to  cause 
paralysis  or  spasm  of  the  vocal  cords,  there  will  be  stridulous  respiration, 
with  dysphonia  or  aphonia,  and  inspection  of  the  larynx  will  usually  reveal 
the  existence  of  paralysis  of  the  cord  on  the  corresponding  side,  with 
possible  paresis  of  the  other.  Occasionally  the  pressure  is  upon  both 
nerves,  with  consequent  paralysis  of  both  vocal  cords. 

Ferdinand  Schnell  (Milnchener  medicinische  Wochenschrift,  April, 
1890)  claims  a  new  means  for  diagnosis  of  deep-seated  thoracic  aneu- 
risms in  the  aneurismatoscope.  This  consists  of  a  soft  rubber  tube 
closed  at  the  lower  end  and  filled  with  colored  fluid,  a  piece  of  glass 
tubing  being  inserted  into  the  upper  end.     When    this    apparatus  is 


262  CARDIAC  AND  ARTERIAL  DISEASES. 

partly  inserted  into  the  oesophagus,  it  is  said  that  the  pulsations  of  an 
aneurism  of  the  descending  arch  are  communicated  to  the  tube  and  are 
indicated  in  the  rise  and  fall  of  the  fluid. 

Diagnosis. — Aneurism  of  the  thoracic  aorta  may  be  confounded 
with  solid  tumors;  with  aortic  pulsation,  due  to  regurgitation  through 
the  semilunar  valves ;  with  pulsating  empyema;  with  dilatation  of  the 
auricle;  and  with  consolidation  of  the  anterior  border  of  the  lung,  with 
aneurism  of  the  pulmonary  artery,  and  with  aneurism  of  the  arteria  in- 
nominata. 

Venous  turgescence,  displacement  of  the  heart,  dulness  on  percus- 
sion, and  modifications  of  the  respiratory  sounds,  due  to  pressure,  are 
signs  common  to  these  and  to  other  varieties  of  intrathoracic  tumors. 
Variation  in  the  force  and  volume  of  the  pulse  on  the  two  sides,  expan- 
sile pulsation  of  the  tumor,  with  a  shock  and  bruit,  are  usually  charac- 
teristic of  aneurisms,  but  occasionally  even  these  signs  may  be  caused  by 
solid  growths.  A  diastolic  bruit  and  shock  over  an  intrathoracic  tumor, 
accompanied  by  a  clear  second  sound  at  the  base  of  the  heart,  is  diagnos- 
tic of  aneurism,  especially  if  following  a  distinct  S}Tstolic  bruit  and  shock. 
A  murmur  at  the  base  of  the  heart,  taking  the  place  of  the  second 
sound,  when  associated  wTith  the  signs  of  a  tumor  in  the  course  of  the 
aorta,  is  valuable  evidence  of  probable  atheromatous  degeneration  of 
the  aorta,  and  the  formation  of  an  aneurism. 

The  differential  features  between  aortic  and  pulmonary  aneurisms 
and  other  diseases  are  pointed  out  below. 

Aneurisms  may  be  distinguished  from  other  intrathoracic  tumors  by 
attention  to  the  history  and  symptoms  as  well  as  to  the  physical  signs. 

The  distinctive  features  between  aneurism  of  the  aorta  and  solid 
tumors  are  as  follows ; 


Aneurism  of  the  aorta.  Solid  tumors. 

History. 

Seldom  or  never  occurring  before  the  Usually  malignant.     They  may  oc- 

twenty -fifth  year  of  age,  and  usually  cur  in  early  life,  and  not  infrequently 

not  until   after    the  forty-fifth    year.  before  the  twenty-fifth  year.     Grave 

Slight,  if  any,  constitutional   disturb-  constitutional  disturbance, 
ance. 

Symptoms. 

Pain  constant, and  of  a  burning,  wear-  Pain  not  so  deep-seated  as  in  aneu- 

ing,  or  aching  character  and  usually  rism;   may  be  sharp  and  lancinating 

aggravated  by  exercise;  frequentlj7  sub-  in  character;  not  affected  by  exercise; 

ject  to  neuralgic  exacerbations.     The  not  subject  to  neuralgic  exacerbations, 

symptoms  and  signs  of  pressure  vary  The  symptoms  and  signs  of  pressure 

from  time  to  time,  owing  to  changes  in  are   constant,    and   steadily    increase 

the  direction  of  the  pressure.  from  day  to  day. 


ANEURISM  OF  THE  AORTA. 


263 


Aneurism  of  the  aorta. 

Signs. 

Expansile  pulsation.  Often  dispar- 
ity between  the  radial  pulses  of  the  two 
sides.  The  area  of  dulness  small  in 
proportion  to  the  size  of  the  tumor  and 
the  length  of  its  history.  Sense  of  re- 
sistance slight. 


Solid  tuhors. 


No  pulsation,  or  if  any,  simply  a 
slight  lifting  impulse,  caused  by  the 
tumor  resting  upon  a  large  artery. 
Usually  no  disparity  in  the  pulse  of  the 
two  sides. 

Area  of  dulness  large,  and  rapidly 
increases.  Sense  of  resistance  well 
marked. 


Aortic  aneurism  is  distinguished  from  aortic  pulsation  by  the  fol- 
lowing symptoms  and  signs: 


Aneurism  of  the  aorta. 


Aortic  pulsation. 


Symptoms. 


Symptoms  of  pressure  upon  the 
trachea,  oesophagus,  or  recurrent  la- 
ryngeal nerve. 

Signs 
Pulsation  in  a  limited  space  over  the 
arch  of  the  aorta. 


No  symptoms  of  pressure. 


Radial  pulse  not  exaggerated  on 
either  side  by  elevation  of  arm;  usually 
feeble  on  one  side. 

Increased  area  of  aortic  dulness. 

Arterial  bruits,  systolic  or  diastolic, 
generally  distinct  from  endocardial 
murmurs. 


Pulsation  not  only  over  the  aorta, 
but  in  the  carotids,  subclavians,  and 
brachials. 

Pulse  sharp  and  apparently  forcible; 
hammer  pulse  exaggerated  by  eleva- 
tion of  the  arm,  and  alike  on  both  sides. 

No  increase  in  the  area  of  dulness. 

Aortic  regurgitant  murmur,  but  no 
special  bruit  over  the  pulsating  vessel. 


Aneurism  may  be  simulated  by  pulsating  empyema,  but  ordinarily" 
it  can  be  easily  distinguished  by  its  position.  If,  however,  perforation 
of  the  chest  walls  should  take  place  in  the  course  of  the  aorta,  as  in  a 
case  recorded  by  Flint,  the  diagnosis  would  be  much  more  difficult. 


Aneurism  of  the  aorta. 

Symptoms 

Symptoms  and  signs  of  pressure  up- 
on adjacent  organs. 

Dulness  confined  to  the  region  of  the 
aorta. 

Arterial  bruits.  No  pulmonary 
signs,  unless  there  be  pressure  upon 
the  trachea,  bronchus,  or  lung  itseif. 
Expansile  pulsation  of  the  tumor. 


Pulsating  empyema, 
and  Signs. 

Usually  no  symptoms  of  pressure 
upon  the  trachea,  oesophagus,  and 
other  adjacent  organs. 

Dulness  or  flatness  over  the  pulsat- 
ing tumor,  and  also  over  the  lower  part 
of  one  siae. 

No  bruit.  Signs  due  to  compression 
of  tne  lung  by  nuid  in  the  pleural  sac. 
Pulsation  somewnat  similar  to  that  of" 
aneurisms,  buc  usually  less  expansile. 


264  CARDIAC  AND  ARTERIAL  DISEASES. 

An  aneurism  of  the  aorta  is  distinguished  from  a  dilated  auricle  as 
follows : 

Aneurism  of  the  aorta.  Dilated  auricle. 

Symptoms  and  Signs. 
Signs  and  symptoms  due  to  pressure  Few,   if  any,   signs  and    symptoms 

upon  adjacent  organs.     Pulsation  fol-        of  pressure.     Pulsation  preceding  the 
lowing  the  systole  of  the  ventricles  and        apex  beat, 
the  apex  beat. 

Dulness  in  the  region  of  the  aorta.  Dulness  extending  far  beyond  the 

Arterial  bruits  common,    but    propa-        region  of  the  aorta,  and  usually  at  a 
gated  mostly  over  the  arteries.  lower  level ;  usually  endocardial  mur- 

murs propagated  in  directions  different 
from  those  of  the  aneurismal  bruit. 

Aneurism  of  the  aorta  is  differentiated  from  consolidation  of  the 
hot 'j  by  the  position  of  the  dulness  and  by  the  signs  upon  ausculta- 
tion. If  the  consolidation  is  due  to  an  aneurism,  care  must  be  taken 
not  to  overlook  the  signs  of  the  latter. 

Aneurism  of  the  aorta.  Consolidation  of  the  lung. 

Signs. 
Durness  limited  to  the  course  of  the  Dulness    not   limited  to  the  aortic 

aorta.  region,  but  extending  externally,  and 

usually  involving  the  whole  apex  of  the 
lung. 
A  normal  respiratory  murmur  may  Rales  and  other  signs  of  consolida- 

often  be  heard  over  the  greater  portion        tion.     No  bruits  excepting  possibly  a 
of  the  aneurism.     Arterial  bruits.  systolic  subclavian  murmur. 

Aneurism  of  the  Pulmonary  Artery. — Aneurism  of  the  pulmonary 
artery  is  one  of  the  rarest  affections  of  the  circulatory  system.  From 
the  few  cases  which  have  keen  described,  we  are  unable  to  obtain  any 
characteristic  symptoms  or  signs.  The  principal  indications  which  have 
been  noticed  are:  extreme  cyanosis,  with  dropsy  and  great  dyspnoea, 
associated  with  a  strongly  pulsating  tumor,  located  in  the  second  inter- 
costal space  of  the  left  side,  and  limited  to  this  region.  This  tumor  is 
likely  to  yield  a  thrill  upon  palpation.  Upon  auscultation,  systolic  or 
diastolic  murmurs,  or  both,  may  be  detected,  but  they  are  not  propagated 
above  the  clavicles.  It  is  hardly  possible  to  distinguish  aneurism  of  the 
pulmonary  artery  from  one  of  the  aorta,  which  happens  to  present  to  the 
left  of  the  sternum. 

The  position  of  a  pulmonary  aneurism  is  different  from  that  of  most 
aneurisms  of  the  aorta.  An  aneurism  of  the  ascending  portion  of  the 
aorta  might  possibly  present  to  the  left  of  the  sternum,  though  in  this 
locality  we  are  more  likely  to  observe  aneurism  of  the  descending  aorta. 
The  distinctive  features  between  aortic  aneurisms  and  those  of  the  pul- 


ANEURISM   OF  THE  AORTA.  205 

monary  artery  may  be  stated,  from  the  symptoms  and  signs  which  have 
been  observed  up  to  the  present  time,  as  follows: 

ANEURISM  OF  THE  AORTA.         ANEURISM  OF  THE  PULMONARY  ARTERY. 

Aneurism  of  the  ascending  arch  pre-  The  tumor  is  confined  to  the  second 

sents  to  the  right  of  the  sternum,  and  intercostal  space  of  the  left  side, 
those  of  the  descending  arch  usually 
present  behind  at  the  left  of  the  third 
dorsal   vertebra,    and    very    rarely   in 
front. 

Signs  and  symptoms  due  to  pressure  The  signs  of  pressure  are  compara- 

upon  the    trachea,    bronchial    tubes,  tively  slight,  but  usually  there  is  con- 

cesophagus,  blood-vessels,  or  recurrent  gestion  of  the  face,  anasarca,  and  great 

laryngeal  nerve,  common.  dyspnoea. 

Bruits,  which  may  be  propagated  in-  Bruits,  not    propagated    above   the 

to  the  carotids  and  subclavians.  clavicles. 

Aneurism  of  the  Arteria  Innominata. — Aneurisms  of  the  arteria 
innominata  cause  pulsating  tumors  similar  to  those  of  the  aorta. 

An  aneurism  of  the  arteria  innominata  may  be  distinguished  from 
an  aneurism  of  the  arch  of  the  aorta — first,  by  its  position ;  second,  by 
the  comparative  absence  of  signs  due  to  pressure;  and  third,  by  the 
effect  on  the  pulsation  of  compression  of  the  subclavian  and  carotid  arte- 
ries. Such  an  aneurism  is  located  entirely  upon  the  right  side  of  the 
sternum,  and  causes  a  prominence  in  the  region  of  the  inner  end  of  the 
clavicle.  It  is  not  likely  to  cause  much  pressure  upon  the  recurrent 
laryngeal  nerve  with  consequent  obstruction  of  the  larynx;  or  on  the 
oesophagus,  so  as  to  interfere  with  deglutition ;  or  upon  the  trachea  so  as 
to  cause  dyspnoea.  Compression  of  the  carotid  or  subclavian  artery  on 
the  affected  side  greatly  diminishes  the  pulsation  in  an  aneurism  of 
the  innominate  artery,  but  does  not  affect  the  pulsation  of  an  aneurism 
involving  the  arch  of  the  aorta  alone. 

Prognosis. — The  average  duration  of  thoracic  aneurism  is  two  years 
and  a  half  (Loomis,  Practical  Medicine).  Eecovery  rarely  occurs.  In 
some  cases  the  affection  seems  to  remain  stationary  for  many  months. 
Death  may  occur  suddenly  at  anytime;  the  prognosis  as  to  duration 
is  therefore  extremely  uncertain.  It  depends  somewhat  upon  the  posi- 
tion of  the  aneurism,  the  structures  pressed  upon,  and  the  occupation, 
temperament,  habits  and  general  health  of  the  individual.  Death 
usually  occurs  from  rupture  of  the  sac,  but  may  be  due  to  asphyxia, 
pneumonia,  gangrene,  or  cerebral  embolism. 

Treatment. — A  mixture  composed  of  equal  parts  of  tincture  of 
belladonna  and  chloroform  liniment  has  been  recommended  for  relief 
of  pain,  but  when  this  is  acute  opiates  will  generally  be  required  for 
temporary  relief.  The  persistent  boring  pain  will  usually  be  greatly  or 
completely  relieved  after  a  day  or  two  by  potassium  iodide  given  in 
doses  of  gr.  x.   to  xx.,  three  or  four  times  a  day.     These  methods  of 


266  CARDIAC  AND   ARTERIAL   DISEASES. 

treatment  have  been  successfully  employed  in  a  few  cases  for  the  relief 
or  the  cure  of  aneurisms. 

Tufnell's  method,  which  in  several  cases  has  succeeded  in  at  least 
greatly  relieving  the  patient,  is  a  modification  of  Valsalva's  starvation 
plan.  It  consists  of  perfect  rest  in  the  recumbent  position  with  mod- 
erate diet. 

Ciniselli's  method  of  galvano  puncture  first  proposed  in  1846  has 
been  successfully  employed  in  a  few  cases  and  may  be  tried  if  the  fore- 
going methods  fail.  It  is  especially  applicable  in  sacculated  aneurisms 
near  to  the  surface.  Before  making  the  puncture  the  patient  may  be 
given  a  full  dose  of  morphine,  or  a  small  amount  of  cocaine  may  be  in- 
jected at  the  joints  when  the  needles  are  to  be  inserted.  From  fifteen 
to  thirty  small  cells  should  be  used,  and  insulated  needles  connected 
with  both  poles  should  be  thrust  vertically  into  the  aneurism  an  inch  or 
two  apart.  Electrolysis  should  be  continued  fifteen  or  twenty  minutes 
and  may  be  repeated  after  a  week  if  necessary.  Great  care  should  be 
used  in  withdrawing  the  needles  to  avoid  loosening  the  clot. 

During  and  after  the  operation,  the  patient  should  be  kept  quiet  in 
the  recumbent  position. 

Another  method  consists  of  the  use  of  large  doses  of  potassium 
iodide.  This  treatment  usually  soon  relieves  the  severe  neuralgic  pains, 
and  possesses  the  advantage  of  allowing  the  patient  to  move  about,  though 
it  is  more  effective  if  the  patient  can  be  kept  continuously  in  a  recum- 
bent position.  The  remedy  should  be  given  in  doses  of  ten  to  thirty 
grains  three  times  a  day.  The  larger  dose  is  much  the  best.  Coryza 
may  be  relieved  by  moderate  doses  of  nux  vomica.  If  the  stomach  be- 
comes irritable,  the  medicine  should  be  suspended  for  a  few  days. 
Sometimes  patients  will  bear  large  doses  who  cannot  tolerate  small  ones. 

"When  an  aneurism  causes  dyspnoea  through  spasm  or  paralysis  of  the 
vocal  cords,  tracheotomy  may  be  necessary;  but  this  operation  can  do 
no  good  when  the  difficulty  of  breathing  results  from  pressure  on  the 
trachea. 

COARCTATION  OF  THE  AORTA. 

Synonym. — Stenosis  of  the  aorta. 

Coarctation  of  the  aorta  is  one  of  the  very  rare  affections  of  the  cir- 
culatory system.  The  constriction  may  be  ring-like,  as  though  a  cord 
had  been  tied  about  the  artery;  it  may  consist  of  a  cicatricial  band,  par- 
tially obstructing  the  calibre  of  the  blood-vessel;  or  it  may  be  due  to  irreg- 
ular contraction  of  the  artery,  the  result  of  inflammation.  The  nar- 
rowing of  the  vessel  may  be  slight,  or  the  aorta  may  have  dwindled  to 
an  impervious  cord.  In  a  few  instances  the  constriction  has  been  found 
to  be  general,  involving  both  the  arch  and  the  descending  aorta.  In 
such  cases  usually  no  symptoms  have  been  observed  until  about  the  age 


SOLID  MEDIASTINAL  TUMORS.  267 

of  puberty,  when  deficient  development  of  the  lower  extremities,  and  es- 
pecially of  the  sexual  organs,  has  been  the  first  indication  of  the  condi- 
tion. 

Inspection  reveals  signs  of  hypertrophy  and  more  or  less  dilatation 
of  the  heart;  usually,  dilatation  of  the  arch  of  the  aorta,  of  the  subclavian 
arteries,  and  of  the  carotids;  a  dilated  and  tortuous  condition  of  the 
superficial  arteries,  which  in  the  normal  state  are  not  visible.  This  con- 
dition of  the  superficial  arteries  is  attended  by  marked  pulsation,  and 
sometimes  by  small  aneurismal  enlargements  of  the  intercostal  arteries 
which  may  be  sufficient  to  cause  erosion  of  the  ribs. 

A  thrill  can  generally  be  detected  by  palpation  over  the  large  arteries. 
The  obstruction  of  the  vessel  renders  the  pulsation  feeble  in  the  branches 
of  the  abdominal  aorta,  and  causes  feebleness  or  absence  of  the  pulse  in 
the  tibial  and  popliteal  arteries.  Percussion  gives  no  signs.  On  auscul- 
tation, a  harsh,  high-pitched,  and  usually  intense  systolic  or  postsystolic 
murmur  will  be  heard  over  the  aorta  and  larger  blood-vessels.  This  is 
usually  most  intense  close  to  the  edge  of  the  sternum  in  the  second  in- 
tercostal space  upon  the  right  side.  This  murmur  is  propagated  through 
the  carotids  and  subclavians  toward  the  shoulder,  and  may  also  be  heard 
posteriorly  over  the  course  of  the  aorta. 

The  occurrence  of  such  a  murmur  will  lead  us  to  suspect  the  exist- 
ence of  an  aneurism;  but  the  latter  may  be  excluded  by  absence  of  the 
symptoms  and  signs  clue  to  pressure,  and  by  the  want  of  an  increased 
area  of  dulness  on  percussion. 

Diagxosis. — The  diagnosis  of  coarctation  of  the  aorta  rests  mainly 
upon  the  enlarged  and  tortuous  condition  of  the  superficial  arteries  in 
the  upper  portion  of  the  body,  and  the  feeble  pulsation  in  the  lower  ex- 
tremities, associated  with  an  aortic  systolic  murmur. 

Tebatmeut. — ISTo  treatment  can  be  recommended. 

SOLID  MEDIASTINAL    TUMORS. 

Excluding  aneurisms,  tumors  within  the  chest  are  nearly  always  ma- 
lignant in  character,  and  are  therefore  attended  with  grave  constitutional 
symptoms;  some  are  of  syphilitic  and  others  of  tubercular  origin. 

Symptomatology. — A  growth  usually  causes  pain  of  a  persistent 
character,  sometimes  lancinating,  but  not  subject  to  the  neuralgic  par- 
oxysms which  attend  an  aneurism. 

The  principal  signs  are:  tnrgescence  of  the  veins,  oedema,  dyspnoea, 
dysphagia,  and  other  evidences  of  pressure  on  surrounding  organs,  with 
dulness  and  loss  of  respiratory  murmurs  over  the  growth. 

By  inspection  we  commonly  find  persistent  turgescence  of  the  veins, 
and  oedema  of  the  neck  and  upper  extremities  in  a  more  marked  de- 
gree than  from  an  aneurism.  A  tumor  is  nearly  always  accompanied 
by  enlargement  of  the  lymphatic  glands  in  the  neck  and  axillary  re- 


268  CARDIAC  AND  ARTERIAL  DISEASES. 

gions.  The  condition  of  these  glands  is  an  important  point  in  the 
differential  diagnosis;  for,  if  it  is  due  to  malignant  disease,  they  will 
be  adherent  to  the  surrounding  tissues,  but,  if  the  conditions  are  not 
of  malignant  origin,  they  may  usually  be  moved  freely  beneath  the  in- 
tegument. The  symptoms  and  signs  caused  by  pressure  on  the  sur- 
rounding organs  are  persistent,  and  they  gradually  increase  in  severity. 
A  malignant  tumor  is  not  usually  confined  to  the  course  of  the  aorta, 
but  is  apt  to  extend  a  considerable  distance  beyond  the  borders  of  the 
sternum.  A  solid  tumor  does  not  ordinarily  pulsate,  and,  when  it  does, 
the  pulsation  is  not  expansile,  but  is  simply  lifting.  This  impulse  is 
caused  by  the  pulsation  of  a  large  artery  upon  which  the  tumor  rests. 

On  percussion,  the  sense  of  resistance  is  marked,  and  the  area  of  dul- 
ness  is  usually  much  larger  than  over  an  aneurism,  because  the  malig- 
nant disease  gradually  involves  the  adjacent  lungs,  instead  of  crowding 
them  before  it. 

By  auscultation,  no  bruit  can  be  heard  over  a  tumor,  unless  it  presses 
upon  an  artery,  and  then  the  murmur  is  distant  and  comparatively 
feeble. 

Exceptional. — In  those  unique  cases  where  a  tumor  coexists  with  a  quies- 
cent aneurism,  some  peculiar  phenomena  have  been  observed.  The  sense  of  re- 
sistance to  the  percussion  stroke  over  an  aneurism  may  be  great ;  whereas  over 
a  solid  tumor  there  may  be  only  slight  resistance,  and  in  the  same  position  we 
may  detect  an  expansile  pulsation,  which  should  naturally  be  found  over  an 
aneurism. 

Diagnosis. — The  essential  features  which  enable  us  to  distinguish 
between  a  solid  tumor  within  the  chest  and  an  aneurism  were  referred 
to  in  the  consideration  of  aneurisms. 

Pkognosis. — Sarcomata  and  carcinomata  of  the  mediastinum  are 
commonly  fatal  within  a  twelvemonth.  Syphilistic  growths  will  often 
subside  under  proper  remedies.  Enlargement  of  the  bronchial  glands 
is  not  infrequently  followed  by  suppuration,  and  often  eventually  termi- 
nates fatally. 

Tkeatjient. — No  special  treatment  can  be  recommended  excepting 
that  indicated  by  the  constitutional  dyscrasia. 


Diseases  of  the  Throat. 


CHAPTER  XVI. 

THE  THEOAT. 

EXAMINATION   OF  THE  FAUCES. 

A  consideration  of  the  diseases  of  the  chest  is  very  properly  associ- 
ated with  a  study  of  the  upper  air  passages,  since  diseases  of  the  nose, 
fauces,  pharynx,  or  larynx  often  cause  symptoms  which  simulate  those  of 
pulmonary  affections.  In  some  instances  so  slight  a  difficulty  as  elonga- 
tion of  the  uvula  will  cause  the  symptoms  of  laryngitis,  or  even  the  per- 
sistent cough,  emaciation,  and  other  symptoms  of  the  later  stages  of 
phthisis. 

For  the  examination  of  the  fauces  it  is  generally  necessary  to  depress 
the  tongue.     For  this  purpose  a  great  variety  of  tongue  depressors  have 


Fig.  50.— Turck's  Tongue 
Depressor  (J4  size). 


Fig.  51.— Pocket  Tongue 
Depressor  (2-5  size). 


Fig.  52.— Bosworth's  Tongue 
Depressor  (2-5  size). 


been  devised  which  will  be  found  useful,  but,  if  not  at  hand,  a  spoon- 
handle,  lead-pencil  or  the  forefinger  will  answer  the  purpose. 

For  ordinary  use,  a  spoon-handle  is  perhaps  the  best,  as  many  pa- 
tients object  to  an  instrument  which  is  used  promiscuously.  Of  the 
different  varieties  of  tongue  depressors,  for  carrying  in  the  pocket  those 
which  are  jointed  are  most  convenient  (Fig.  51).  In  office  practice, 
some  of  the  larger,  stronger  varieties  are  preferable  (Figs.  50  and  52). 
Some  patients  can  so  control  the  base  of  the  tongue  as  to  allow  a  view  of 
the  throat  without  the  aid  of  a  depressor,  but  this  is  not  the  rule.  A  fair 
view  may  often  be  obtained  in  children  while  they  are  crying  or  cough- 
ing.    If  the  child  resists,  a  spoon-handle  or  other  depressor  may  be 


272  THE  THROAT. 

passed  well  back  upon  the  base  of  the  tongue,  so  as  to  induce  retching, 
which  will  afford  a  good  view  of  the  pharynx. 

We  should  embrace  every  opportunity  for  inspecting  the  healthy 
throat,  in  order  to  become  familiar  with  its  normal  conditions,  other- 
wise we  are  unable  to  recognize  quickly  the  signs  of  disease.  Upon 
inspection  of  the  healthy  fauces,  we  first  notice  the  soft  palate  with 
the  pendent  uvula,  which  forms  the  back  part  of  the  roof  of  the 
mouth.  Running  downward  from  either  side  of  the  soft  palate  will  be 
seen  two  folds  of  mucous  membrane,  known  as  the  anterior  and  poste- 
rior pillars  of  the  fauces,  between  which  may  be  seen  a  glandular  mass, 
termed  the  tonsil.  Posteriorly  we  observe  the  posterior  pharyngeal  wall, 
which  closely  covers  the  bodies  of  the  cervical  vertebrae.  Superiorly,  our 
field  of  vision  is  obstructed  by  the  palate;  inferiorly,  by  the  base  of  the 
tongue. 

LARYNGOSCOPY. 

In  order  to  look  beyond  the  lines  of  direct  vision,  we  must  use  mir- 
rors. Inspection  of  the  larynx  with  these  is  called  laryngoscopy,  and 
the  same  method  applied  to  the  nasal  passages  and  nasopharynx  is 
called  rhinoscopy.  The  essentials  for  laryngoscopy  are,  a  throat  mirror 
and  a  good  light.  The  combination  of  a  throat  mirror  and  a  reflector 
for  directing  the  light  is  called  a  laryngoscope.  A  reflector  and  smaller 
mirror  used  in  examining  the  nasopharynx  is  called  a  rhinoscope. 

History.— The  credit  of  having-  discovered  the  art  of  laryngoscopy  is  usually 
given  to  Czermak,  of  Pesth,  but  many  before  his  time  had  experimented  more  or 
less  successfully  in  illuminating  the  larynx.  Bozzini  in  the  beginning  of  the 
present  century,  Bennatti  in  1832,  and  Avery,  of  London,  in  1844  attempted  to 
illuminate  the  larynx  by  means  of  artificial  light  conducted  through  tubes  ;  but, 
as  shown  by  Trousseau  and  Bellocq,  these  instruments  crowded  the  tongue  and 
epiglottis  before  them,  so  as  nearly  or  quite  to  close  the  orifice  of  the  larynx. 
At  most,  they  could  expose  only  a  small  portion  of  its  posterior  wall. 

About  a  hundred  years  previous,  to  these  efforts,  Levret,  of  Paris,  probably 
the  first  experimenter  in  this  direction,  attempted  to  see  the  larynx  by  means  of 
a  small  throat  mirror,  similar  to  that  now  in  use.  Senn,  of  Geneva,  in  1827; 
Babbington,  of  London,  in  1829  ;  Baumes,  of  Lyons,  in  1838  ;  and  Liston,  of  Lon- 
don, in  1840,  employed  similar  instruments  with  equally  unsatisfactory  results. 
Warden,  in  1844,  made  experiments  with  a  couple  of  prisms.  All  of  these  in- 
vestigators failed  more  or  less  completely,  for  the  reason  that  they  could  not  se- 
cure suitable  illumination. 

The  first  to  demonstrate  the  larynx  in  the  living  subject  was  Signor  Manuel 
Garcia,  a  teacher  of  vocal  music  in  London.  He  became  quite  expert  in  auto- 
laryngoscopy,  and  also  succeeded  in  demonstrating  the  larynx  in  others. 

Garcia's  observations  were  communicated  to  the  Royal  Society  of  London  in 
1855.  They  attracted  little  attention  at  first,  for  the  art  was  thought  to  be  of  no 
practical  value  in  the  diagnosis  of  disease,  because  a  thorough  inspection  was 
supposed  to  depend  upon  a  peculiar  education  of  the  muscles  which  would  enable 
the  patient  to  control  the  position  and  movements  of  his  throat.  However, 
Garcia's  writings  induced  Tiirck,  of  Vienna,  to  experiment  with  similar  mirrors 


LARYNGOSCOPY. 


273 


in  the  hospital  during  the  summer  of  1857.  Although  Tiirck  was  fairly  successful 
in  these  experiments,  he  finally  threw  aside  his  mirrors  as  the  autumn  came  on, 
because  of  the  difficulty  in  obtaining  sunlight.  His  experiments  were  not  lost, 
for  Czermak,  of  Pesth,  who  had  been  visiting  in  Vienna  during  the  summer,  bor- 
rowed the  mirrors  and  continued  the  investigations.  He  overcame  the  difficulties 
which  had  previously  prevented  a  clear  view  of  the  larynx,  by  employing  the 
reflector  and  causing  the  patient  to  protrude  the  tongue,  instead  of  depressing 
it,  and  by  substituting  artificial  light  for  the  direct  rays  of  the  sun.  Soon  a 
rivalry  sprang  up  between  Czermak  and  Tiirck  as  to  the  priority  of  their  claims. 
Their  letters,  which  were  published  in  the  various  medical  journals,  spread  a 
knowledge  of  the  new  art  throughout  the  medical  world. 

Theoat  mirrors  have  been  made  in  various  forms.     Some  are  round, 
others  oval  or  lozenge-shaped,  and  still  others  quadrilateral.     For  gen- 


Fig.  53.— Throat  Mirrors  for  Laryngoscopy.    1.  a,  Handle;  b,  stem;  c,  mirror. 
sizes  of  round  mirrors.    3.  a,  b,  c,  Different  forms  of  throat  mirrors. 


2.  Different 


eral  use  the  round  mirrors,  varying  in  diameter  from  three-eighths  of  an 
inch  to  an  inch  and  a  quarter  are  preferable.  Mirrors  should  be  made 
of  clear  and  perfectly  white  glass.  The  quality  of  the  glass  may  be 
tested  by  placing  a  white  card  before  the  mirror.  If  the  glass  is  per- 
fectly white,  the  reflection  will  also  be  white;  if  the  glass  is  tinged  with 
color,  it  will  give  a  corresponding  shade  to  the  reflected  image  of  the 
card,  and  would  necessarily  similarly  affect  the  laryngeal  image. 

The  glass  and  its  setting  should  be  thin,  in  order  to  economize  space 
in  the  throat. 

The  glass  should  be  set  firmly  in  a  metallic  frame,  which  must  en- 
croach as  little  as  possible  upon  the  anterior  surface  of  the  glass,  so  that 
the  largest  possible  reflecting  surface  may  be  secured.  Some  of  these 
mirrors  are  backed  with  amalgam,  and  others  with  silver-leaf.     Silver- 


;2T4  THE  THROAT. 

leaf  renders  a  mirror  more  durable,  as  it  is  less  affected  by  beat  and 
moisture.  I  bave  used  mirrors  backed  with  amalgam  many  times  daily 
for  several  months  without  injuring  them,  though  one  may  be  ruined  in 
a  week  if  heated  too  much  or  left  in  the  water.  The  mirror  should  be 
firmly  attached  to  a  wire  stem  about  four  inches  in  length,  at  an  angle 
of  not  less  than  one  hundred  and  twenty  degrees.  This  stem  may  be 
fixed  in  a  small  handle  about  three  inches  long,  or  the  handle  may  be 
removable,  the  stem  when  inserted  being  held  by  a  set-screw.  Some 
laryngologists  recommend  a  flexible  stem,  so  that  the  angle  of  the  mirror 
can  be  easily  altered;  but  it  is  likely  to  become  bent  by  contraction  of 
the  palatine  muscles,  when  the  mirror  is  in  position,  in  such  a  manner 
that  the  larynx  cannot  be  seen. 

An  inflexible  stem  is  always  preferable,  for  the  obliquity  of  the  mir- 
ror can  be  easily  altered  b}*  elevating  or  lowering  the  handle.  If  the 
beginner  attempts  to  alter  the  obliquity  of  the  mirror  by  bending  the 
stem,  he  is  likely  to  break  the  instrument  in  his  frequent  attempts  to 
secure  an  angle  which  will  give  a  different  view  of  the  larynx;  and  it  is 
better  for  him  to  attribute  want  of  success  to  lack  of  skill  rather  than  to 
a  defect  in  the  mirror. 

Illumination. — To  obtain  a  perfect  illumination  of  the  larynx,  three 
things  are  necessary :  first,  the  eye  should  be  brought  as  nearly  as  pos- 
sible into  the  centre  of  the  beam  of  light  used  in  the  illumination;  second, 
the  light  should  be  bright,  especially  if  a  small  throat  mirror  is  used, 
for  the  smaller  the  mirror  the  fewer  the  rays  which  can  be  reflected 
from  it,  and  we  must  make  up  in  intensity  what  is  lost  in  volume; 
third,  the  focal  point,  when  convergent  rays  are  used,  should  fall  upon 
the  part  to  be  inspected. 

All  forms  of  illumination  which  cast  convergent  rays  into  tbe  larynx 
cause  above  and  below  the  focal  point  what  are  known  as  circles  of  dis- 
persion, in  which  the  illumination  for  a  short  distance  is  nearly  as  bright 
as  at  the  focal  point.  In  examining  the  larynx,  an  effort  should  be 
made  to  concentrate  the  rays  of  light  on  the  vocal  cords;  the  circles  of 
dispersion  will  then  give  a  good  illumination  for  half  an  inch  above  or 
below  the  plane  of  the  glottis.  In  men,  the  glottis  is  about  three  inches 
below  the  mirror  when  it  is  held  in  the  posterior  part  of  the  mouth,  and 
in  this  position  the  mirror  is  about  three  inches  from  the  lips;  therefore 
in  men  the  glottis  is  about  six  inches  within  the  lips,  but  in  women  about 
five  inches.  As  the  eye  cannot  be  brought  nearer  to  the  mouth  than  five 
inches,  without  interfering  with  the  manipulation  of  the  instrument,  the 
radiant  or  focal  point  must  fall  eleven  inches  from  the  reflector,  which 
is  worn  on  the  forehead. 

Being  myself  hypermetropic,  I  find  it  most  convenient  to  have  the 
eye  at  least  eight  inches  from  the  patient's  mouth;  and  therefore  must 
use  a  reflector  which  will  concentrate  the  rays  of  light  at  a  point  four- 
teen inches  from  itself. 


LARYNGOSCOPY.  275 

Persons  with  presbyopic  eyes  may  obtain  a  good,  view  in  the  same 
manner;  deficient  accommodation  in  the  eye  maybe  corrected  by  glasses. 

Myopic  eyes  of  less  than  one-tenth  will  necessitate  the  use  of  concave 
glasses;  but  for  eyes,  myopic  from  one-tenth  to  one-seventeenth,  glasses 
will  not  be  needed,  excejDting  to  view  the  bifurcation  of  the  trachea. 

To  examine  the  bifurcation  of  the  trachea,  wbich  is  five  or  six  inches 
below  the  plane  of  the  vocal  cords,  we  must  remember  that  the  focal 
point  should  be  at  least  sixteen  or  seventeen  inches  distant  from  the 
reflector. 

The  larynx  may  be  illuminated  by  a  simple  flame,  or  a  plane  or  con- 
cave reflector  with  or  without  condensing  lenses  may  be  employed  to 
reflect  the  rays  of  light  into  the  throat.  In  illuminating  the  larynx  by 
the  direct  rays  of  the  sun,  lenses  are  not  used,  and  reflectors  are  not 
absolutely  necessary.  When  diffused  daylight  is  employed,  reflectors  are 
required  to  concentrate  the  rays.  Though  direct  sunlight,  or  sometimes 
diffused  daylight,  gives  a  beautiful  illumination,  artificial  light  will  be 
found  indispensable  for  general  use.  Natural  light  cannot  usually  be 
secured  in  the  proper  position  at  the  time  we  wish  to  use  it. 

Illumination  with  Direct  Artificial  Light. — When  using  a  simple  flame 
without  a  reflector,  the  lamp  must  be  placed  directly  in  front  of  the 
patient's  mouth,  and  shaded  toward  the  eye  of  the  observer.  This  will 
give  a  good  illumination  if  the  light  is  very  bright,  but  with  the  ordi- 
nary lamp  or  gas-jet  it  is  not  satisfactory,  This  method  may  be  im- 
proved by  using  a  condensing  lens  with  a  focal  distance  of  six  or  seven 
inches.  The  lens  should  be  held  between  the  light  and  the  patient's 
mouth,  and  about  five  inches  from  the  latter.  The  flame  should 
be  placed  at  a  point  which  will  cause  its  rays  to  be  brought  to  a  focus 
eleven  inches  beyond  the  lens  at  the  plane  of  the  glottis.  The  obser- 
ver's eye  must  then  be  brought  near  the  edge  of  the  lens. 

Illumination  with  Reflected  Artificial  Light. — The  above-named  ap- 
paratus may  be  supplemented  by  a  plane  perforated  reflector,  which,placed 
in  front  of  the  observer's  eye,  reflects  into  the  mouth  the  rays  from  the 
condensing  lens;  or  this  reflector  may  be  used  with  the  simple  flame 
without  a  condenser. 

In  order  to  fulfil  the  three  essential  conditions — that  is,  to  have  the 
eye  in  the  centre  of  the  cone  of  light,  to  obtain  a  bright  illumination, 
and  to  have  the  focal  point  fall  upon  the  part  to  be  examined — laryngol- 
ogists  generally  resort  to  a  perforated  concave  reflector.  Such  a  mirror, 
by  collecting  many  rays  otherwise  lost,  and  concentrating  them  on  the 
point  to  be  examined,  intensifies  the  illumination,  and  the  perforation 
in  its  centre  brings  the  observer's  eye  into  line  with  the  centre  of  the 
cone  of  light.  Many  laryngologists  prefer  to  place  the  reflector  above 
the  eye,  but  unless  a  very  bright  light  is  employed  this  position  will  not 
give  a  good  illumination  of  the  larynx,  and  if  a  brilliant  light  is  used  it 
is  very  trying  to  the  eyes. 


270  THE  THROAT. 

The  reflectors  vary  in  size,  in  focal  distance,  and  in  the  maierial  of 
which  they  are  constructed.  Those  used  in  laryngoscopy  are  usually 
from  three  to  four  inches  in  diameter,  with  a  focal  distance  ranging 
from  five  or  six  to  fourteen  or  sixteen  inches.  They  are  made  of  either 
glass  or  metal;  the  former  are  best,  as  they  do  not  become  dim  by  tar- 
nishing. For  ordinary  use,  a  reflector  with  a  focal  distance  of  seven  or 
eight  inches  will  give  better  satisfaction  than  one  with  a  longer  focus, 
except  when  parallel  rays  of  light,  as  those  of  the  sun  or  of  diffused  day- 
light are  to  be  reflected.  The  rays  coming  from  any  artificial  light  are 
necessarily  divergent,  and  consequently  cannot  be  brought  to  a  focus  in 
the  larynx  by  a  reflector  with  a  focal  distance  of  eleven  inches,  which 
would  concentrate  only  parallel  rays  at  the  proper  point. 

With  the  ordinary  position  of  the  flame,  and  of  the  observer's  eye,  a 
reflector  of  seven  inches  focal  distance  will  throw  the  radiant  point  upon 
the  glottis.  The  radiant  point  may  readily  be  moved  toward  and  from 
the  eye  by  increasing  or  lessening  the  distance  of  the  flame  from  the 
reflector,  so  that  reflectors  of  varying  focal  distances  may  be  employed, 
providing  the  light  is  sufficiently  intense. 

On  account  of  its  simplicity,  the  formula  -p-  =  -£  +  ~^r  has  been 
generally  adopted  in  determining  the  focal  distance  of  the  reflector,  or 
the  proper  position  of  a  flame,  which,  with  a  reflector  of  known  focal 
distance,  will  cause  the  image  of  the  flame  to  fall  upon  the  glottis. 
The  image  of  the  flame  and  the  radiant  point  are  in  this  connection 
used  as  synonymous  terms.  The  focal  point  is  the  same  as  the  radiant 
point  when  parallel  rays  of  light  are  employed. 

In  this  formula,  F  represents  the  focal  distance  of  the  reflector; 
A,  the  distance  of  the  reflector  from  the  flame;  A'  the  distance  of 
the  reflected  image  of  the  flame  (focal  or  radiant  point)  from  the 
reflector.  Knowing  the  focal  distance  of  the  reflector,  seven  inches, 
and  the  proper  distance  of  the  image  of  the  flame,  which,  as  already 
explained,  should  fall  upon  the  glottis,  and  will  therefore  be  eleven 
inches  from  the  reflector — five  inches  from  the  observer's  eye  to  the 
patient's  mouth,  and  six  inches  from  the  patient's  lips  to  his  vocal  cords 
— we  can  readily  ascertain  the  proper  position  of  the  flame  by  substitut- 
ing the  known  quantities  in  the  formula  thus:  \  =  — ■  -\-  11r.  This,  re- 
duced, will  give  a  fraction  over  nineteen  inches  as  the  value  of  A,  which 
will  represent  the  proper  distance  of  the  flame  from  the  reflector. 

To  find  the  focal  distance  of  the  reflector  by  artificial  light,  we  pro- 
ceed in  a  similar  manner  with  the  same  formula.  Placing  the  light  at 
a  fixed  point  and  the  reflector  in  front  of  it,  we  find  the  distances  from 
the  flame  to  the  reflector,  and  from  the  reflector  to  the  image  of  the 
flame,  by  direct  measurement  with  an  ordinary  tape.  These  two  known 
quantities  being  then  inserted  in  the  formula  in  the  place  of  A  and  A', 
the  value  of  F  can  readily  be  obtained.     The  focal  distance  of  a  reflector 


LARYNGOSCOPY.  277 

may  be  easily  ascertained  with  solar  light  by  placing  it  in  the  sunlight, 
throwing  the  radiant  point  on  some  object,  and  measuring  its  distance 
from  the  centre  of  the  reflector.  The  focal  distance  may  be  measured 
with  diffused  light  by  reflecting  the  image  of  some  distant  object,  as  a 
window,  on  some  plane  surface,  and  measuring  the  distance  from  this 
image  to  the  reflector. 

In  using  reflectors,  it  is  essential  that  the  light  be  so  managed  that 
the  radiant  point  will  fall  on  the  part  to  be  illuminated. 

Students  of  laryngoscopy  usually  have  great  difficulty  in  obtaining 
a  uniform  illumination.  Sometimes  the  parts  will  be  brilliantly  illumi- 
nated; at  other  times  with  the  same  light  and  the  same  laryngoscope  the 
larynx  is  only  seen  in  a  deep  shadow.  This  is  generally  due  to  the  im- 
proper position  of  the  light.  "We  must  not  forget  that  the  larynx  is 
necessarily  from  eleven  to  fourteen  inches  from  the  eye,  and  that,  with  a* 
reflector  of  seven  or  eight  inches  focal  distance,  if  the  flame  be  placed 
too  near  the  eye,  the  radiant  point  will  fall  a  considerable  distance  be- 
yond the  glottis ;  or  if  too  far  from  the  eye,  the  radiant  point  will  not 
reach  the  glottis.  We  should  always  know  the  focal  distance  of  our  re- 
flector, and  ascertain  by  the  formula  just  explained  the  proper  distance  at 
which  to  place  the  flame,  remembering  that  the  distance  of  the  radiant 
point  from  the  reflector  will  vary  inversely  as  the  latter  is  carried  toward 
or  from  the  flame. 

Practically,  if  we  have  a  proper  reflector  of  seven  to  eight  inches 
focal  distance,  it  will  not  be  necessary  to  measure  accurately  the  dis*- 
tance  of  the  flame.  Placing  the  light  beside  the  patient,  we  may  sit  in 
front  with  the  reflector,  ten  or  eleven  inches  from  the  patient's  mouth; 
carry  the  light  forward  or  backward  until  its  perfect  inverted  image 
falls  on  the  patient's  lips,  this  will  be  the  proper  position  for  the  light. 
By  bringing  the  reflector  about  four  inches  nearer  the  mouth,  the  radi- 
ant point  falls  upon  the  glottis. 

Various  contrivances  are  employed  for  holding  the  reflector.  Czermak 
at  first  had  it  fastened  to  a  mouthpiece  of  orris  root,  which  he  held  be- 
tween his  teeth.  Semeleder  and  others  are  in  favor  of  a  spectacle  frame, 
to  which  the  reflector  is  so  fastened  that  it  may  rotate  in  any  direction. 
If  the  physician  happen  to  be  myopic  or  hypermetropic,  lenses  may  be 
fitted  in  this  frame  to  correct  the  error  in  accommodation.  Jointed  arms 
for  holding  the  reflector  accompany  many  forms  of  illuminating  appa- 
ratus. These  are  inconvenient  for,  if  the  patient  moves  after  the  arm 
has  been  adjusted,  each  movement  may  require  a  change  in  the  position 
of  the  reflector.  Kramer's  head  band,  or  some  modification  of  it,  is  the 
most  common,  and,  I  think,  the  best  device  for  holding  the  reflector. 
It  consists  of  a  head  band  with  a  metallic  or  vulcanite  plate  in  front  to 
which  the  reflector  is  attached  by  a  ball-and-socket  joint,  which  enables 
one  to  fix  it  in  any  position.  Most  of  the  head  bands  are  open  to  two 
objections;  first,  they  cannot  be  made  tight  enough  to  hold  the  reflector 


278 


THE  THROAT. 


firmly  without  causing  headache;  and  second,  the  ball-and-socket  joint 
is  so  constructed  that,  after  it  becomes  a  little  worn,  it  is  impossible  to 
fix  the  reflector  firmly.  Schrotter's  head  band  made  of  firm  non-elastic 
webbing,  with  nasal  rest,  obviates  these  difficulties. 


Fig.  54. — Schrotter*s  Head  Band  with  Nasal  Rest. 

Whatever  the  means  employed  for  holding  the  reflector,  it  must  be 
borne  in  mind  that  the  flame  must  have  a  certain  definite  relation  to  the 
reflector,  depending  on  the  focal  distance  of  the  latter  and  its  distance 
from  the  glottis,  so  that  the  image  of  the  flame  will  fall  upon  the  vocal 
cords. 


W  i    dtp! 


Fig.  55.— Krishaber's  Illuminator. 
a,  Lens  ;  b,  reflector. 


Fig.  56.— Modified  Mackenzie's  Rack-movement  Bull's-eye 
Condenser.    For  gas  or  incandescent  electric  light. 


In  place  of  throwing  the  radiant  point  on  the  glottis,  some  physi- 
cians prefer  to  illuminate  the  parts  to  be  examined  with  the  bright  disc 
of  light  which  may  be  obtained  in  the  circle  of  dispersion  above  or 
below  the  radiant  point. 

Several  instruments  have  been  devised  for  the  purpose  of  rendering 
the  light  in  this  disc  more  intense. 


LARYNGOSCOPY. 


279 


One  of  the  simplest  of  these  is  Krishaber's  illuminator  (Fig.  55).  It 
consists  of  a  reflector  and  a  convex  lens,  which  may  be  fastened  by  the 
clamp  to  an  ordinary  lamp. 

This  apparatus  will  often  give  very  satisfactory  results. 

Mackenzie's  bull's-eye  condenser  is  used  for  the  same  purpose.  It 
consists  of  a  rack-movement  gas  fixture  with  a  metallic  chimney,  which 
can  be  adjusted  to  the  ordinary  gas-burner  (Fig.  56).  The  chimney  has 
an  orifice  on  one  side  for  the  condensing  lens,  and  the  latter  is  placed 
at  a  fixed  point  in  front  of  the  flame,  so  that  the  rays  of  light  on  leaving 


Fig.  57.- 


-Modification  of  Mackenzie's  Illuminator,  which  may  be  Used  either  with  a 
Student's  Lamp  or  an  Argand  Gas-burner. 


it  will  be  nearly  parallel.  This  illuminator  may  be  brought  directly  in 
front  of  the  patient's  mouth  for  direct  illumination,  but  it  is  generally 
used  with  a  reflector  of  from  eleven  to  fourteen  inches  focal  distance. 

Fraenkel's  illuminator  is  somewhat  similar  in  construction  as  regards 
the  condensing  lens,  but  is  so  arranged  that  the  rays  of  light  on  leaving 
the  lens  may  be  made  either  divergent,  parallel,  or  convergent,  according 
to  the  size  and  focal  distance  of  the  reflector  which  is  employed. 

In  accordance  with  my  suggestions  a  similar  condenser  has  been  con- 
structed, which  may  be  used  with  the  ordinary  Argand  gas-burner  or  Ger- 
man student's  lamp  (Fig.  57).  In  this  condenser  the  lens,  which  has  a  focal 
distance  of  three  and  one-half  inches,  is  set  about  two  inches  from  the  name, 
so  that  the  rays  of  light  are  divergent  on  leaving  it,  and  are   thus  adapted 


280  THE   THROAT. 

for  a  reflector  with  a  focal  distance  of  seven  or  eight  inches.  If  it  is  desired  to 
obtain  a  bright  circle  of  dispersion  for  illumination,  or  to  use  a  reflector  with  a 
longer  focal  distance,  the  cap  in  which  the  lens  is  set  can  be  drawn  out  so  that 
the  rays  will  be  less  divergent. 

This  condenser  is  comparatively  inexpensive,  and  possesses  all  the  advantages 
of  the  last  two  described,  as  well  as  those  of  Tobold's  illuminator,  without  the 
imperfections  of  the  latter.  With  this  condenser  and  Fraenkel's,  either  the 
radiant  point  or  the  circle  of  dispersion  may  be  used  for  illuminating  the  glottis. 

Tobold's  illuminator,  a  combination  of  lenses  devised  by  Tobold,  is 
in  common  use.  Weil  has  shown  that  the  apparatus  is  improved  by  re- 
moving one  or  two  of  its  lenses.  These  lenses  merely  cause  a  large 
circle  of  dispersion,  which,  though  brilliant  when  thrown  on  an  external 
object,  is,  in  point  of  fact,  less  intense  than  the  image  of  the  flame. 

Tobold's  apparatus  has  a  combination  of  three  lenses,  two  of  which,  each 
having  a  focal  distance  of  about  three  inches,  are  placed  closely  together,  and  so 
near  the  flame  that  they  collect  divergent  rays  as  they  leave  the  lamp,  and  con- 
centrate them  to  a  focus  about  six  inches  in  front  of  the  second  lens.  The  third 
lens,  farthest  from  the  flame,  has  a  focal  distance  of  about  five  inches.  It  is 
placed  four  inches  in  front  of  the  second  lens,  about  two  inches  within  the  point 
at  which  the  rays  of  light  are  concentrated  by  the  latter,  so  that  the  rays  of  light 
falling  on  it  are  convergent.  The  convergent  rays,  bypassing  through  the  third 
lens,  are  rendered  still  more  convergent,  and  are  brought  to  a  focus  about  three 
inches  in  front  of  the  apparatus,  where  the  image  of  the  flame  is  perfect.  The 
reflector  is  fixed  about  four  inches  in  front  of  the  apparatus,  or  one  inch  beyond 
the  radiant  point  of  the  last  lens.  Here  the  rays,  having  crossed,  are  so  widely 
divergent,  that  a  reflector  of  one  and  a  half  inches  focal  distance  would  be  re- 
quired to  concentrate  them  upon  the  glottis.  The  reflector  used  has  a  focal  dis- 
tance varying,  in  different  instruments  examined,  from  five  to  nine  inches.  There- 
fore the  rays  must  also  leave  the  reflector  widely  divergent,  so  that  most  of 
them  will  be  lost.  Hence,  we  see  that  the  large  bundle  of  rays  collected  by  the 
first  lens,  which  might  then  have  been  entirely  utilized,  is  first  subjected  to  the 
loss  incident  to  refraction,  and  then  largely  thrown  away.  We  must  admit 
that  a  sufficient  number  of  rays  are  still  retained  to  give  a  good  illumination, 
though  less  intense  than  when  only  one  lens  is  employed. 

Xo  advantage  can  be  derived  from  such  a  combination,  except  where 
cheap  lenses  of  a  moderate  convexity  are  placed  together  to  secure  a 
short  focal  distance.  A  single  lens  of  sufficiently  high  power  to  ac- 
complish the  same  result  would  be  comparatively  expensive.  Tobold 
has  also  devised  a  smaller  instrument  known  as  the  pocket  illuminator, 
the  construction  of  which  is  similar  to  that  of  the  one  just  described. 

The  image  of  the  flame  may  be  so  magnified  by  a  single  lens,  as  found 
in  the  condensers  already  mentioned,  that  it  is  as  large  as  can  possibly 
be  reflected  from  any  throat  mirror. 

In  using  condensing  lenses,  any  one  of  three  methods  may  be  adopted : 
the  flame  may  be  placed  at  the  focal  point  of  the  lens;  it  may  be  placed 
beyond  the  focal  point ;  it  may  be  placed  nearer  to  the  lens  than  its  focal 
point. 

With  the  flame  at  the  focal  point,  the  rays  which  always  leave  the 


LARYNGOSCOPY.  281 

light  in  a  divergent  direction  are  refracted,  so  as  to  leave  the  lens  in  a 
parallel  direction,  and  they  must  then  be  managed  in  the  same  manner 
as  the  parallel  rays  of  sunlight  or  diffused  daylight.  In  this  instance, 
a  reflector  of  a  diameter  the  same  as  that  of  the  lens  should  be  em- 
ployed, having  a  focal  distance  of  from  eleven  to  fourteen  inches. 
This  will  bring  the  image  of  the  flame  upon  the  glottis,  providing  the 
eye  is  from  five  to  eight  inches  from  the  mouth. 

When  the  flame  is  placed  beyond  the  focal  distance  of  the  lens,  its 
divergent  rays,  after  passing  through  the  lens,  become  convergent.  Here 
the  reflector  may  be  smaller  than  the  lens,  but  it  must  have  a  focal  dis- 
tance of  more  than  eleven  inches;  otherwise  the  rays  will  be  brought  to 
a  focus  too  soon. 

When  the  flame  is  placed  nearer  the  lens  than  its  focal  distance,  the 
rays,  after  passing  through,  are  still  divergent,  and,  in  order  that  none 
be  lost,  they  must  be  received  on  a  reflector  larger  than  the  lens,  which 
must  have  a  focal  distance  of  not  more  than  eight  inches,  the  same  focal 
distance  as  that  required  when  a  flame  is  used  without  a  condensing 
lens.  This  is  by  far  the  best  method  for  practical  purposes,  as  it  gives 
an  illumination  equally  as  good  as  the  other  methods,  and  does  not  ne- 
cessitate the  possession  of  a  number  of  reflectors. 

Some  form  of  condenser  is  desirable  for  office  use,  but  I  have  always 
found  a  simple  concave  reflector  of  large  size  and  short  focal  distance 
sufficient  for  purposes  of  diagnosis,  and  ordinarily  for  operations  within 
the  larynx.  Such  a  reflector  may  be  used  with  an  ordinary  gas-jet  or 
with  any  lamp,  and  may  be  sufficient,  even  if  one  is  obliged  to  rely  on 
candles.  For  general  use  it  will  certainly  be  found  more  satisfactory 
than  a  cumbersome  illuminating  apparatus. 

When  performing  operations  in  the  larynx,  it  is  desirable  to  have  as 
large  a  field  illuminated  as  possible.  This  may  be  attained  by  means  of 
the  bull's-eye  condenser  with  the  ordinary  flame,  or  with  a  brighter  light 
and  a  reflector  with  a  long-  focal  distance,  so  that  the  circle  of  dispersion 
can  be  utilized  in  place  of  the  radiant  point. 

Several  laryngoscopes,  illuminated  by  electric  light,  have  been  in- 
vented, but  they  are  not  usually  so  satisfactory  as  the  simple  reflector 
and  Argand  burner  or  German  student's  lamp. 

A  bright  electric  light,  if  properly  arranged,  would  perhaps  be  the 
best  for  laryngoscopy,  and,  next  to  it,  the  oxyhydrogen  light.  The 
former,  however,  cannot  always  be  obtained,  and  the  latter,  besides 
being  difficult  to  manage,  requires  a  great  deal  of  apparatus,  and  is 
consequently  expensive.  A  good  Argand  gas-burner  or  a  German  stu- 
dent's lamp  with  a  bull's-eye  condenser  is  all  that  is  necessary  for 
illumination,  even  during  operations.  I  have  sometimes  obtained  brill- 
iant illumination  even  with  a  common  kerosene  lamp,  having  a  circular 
wick  like  that  shown  in  Fig.  55.  For  purposes  of  diagnosis,  any  ordi- 
nary lamp,  freshly  trimmed,  and  Avith  a  clean  chimney,  wiK  generally  be 


282  THE  THROAT. 

sufficient.  As  suggested  by  J.  Solis  Cohen,  two  or  three  candles  tied 
together,  and  placed  in  front  of  the  bowl  of  a  spoon  used  as  a  reflec- 
tor, may  be  made  to  answer  the  purpose  if  a  lamp  cannot  be  obtained. 

Diffused  daylight,' when  properly  managed,  gives  a  beautiful  illumi- 
nation of  the  larynx.  Artificial  light  more  or  less  discolors  the  image, 
causing  the  normal  larynx  to  appear  yellowish  or  red,  whereas  diffused 
daylight  shows  the  parts  in  their  natural  colors.  Unfortunately  the 
latter  is  seldom  sufficiently  bright.  On  a  bright  day,  if  light  can  be 
admitted  through  a  small  opening  into  a  darkened  room,  so  as  to  fall 
upon  the  reflector,  it  will  give  a  good  illumination.  If  it  is  impossible 
to  admit  the  light  through  a  small  aperture,  a  good  view  may  sometimes 
be  obtained  by  placing  the  patient  at  the  farther  side  of  the  room,  op- 
posite a  single  window  left  uncovered,  with  his  back  to  the  light.  This 
position  will  give  a  much  better  view  than  when  the  patient  is  placed 
near  the  window. 

Direct  sunlight  may  be  employed,  with  the  patient  facing  the  win- 
dow, in  such  a  position  that  the  rays  fall  upon  the  throat  mirror  held  in 
the  pharynx.  A  serious  hindrance  to  this  method  is  that  the  light  can- 
not often  be  obtained  in  a  suitable  position.  Reflected  sunlight  may 
more  frequently  be  employed  with  the  aid  of  a  plane  reflector,  or  of  one 
with  a  long  focal  distance,  but  it  is  only  in  comparatively  rare  instances 
that  we  have  a  proper  exposure  and  find  the  sun  at  the  desired  altitude. 

Heliostats  have  been  constructed  for  reflecting  the  sunlight  in  a 
given  direction.  They  may  be  arranged  by  a  system  of  clockwork  to 
maintain  the  beam  of  light  at  a  given  point  throughout  the  day.  This 
apparatus  is  very  expensive,  and  not  to  be  recommended. 

An  ordinary  toilet  mirror  may  be  so  placed  as  to  receive  a  beam  of 
sunlight,  and  direct  it  horizontally  in  any  desired  direction;  but  this  is 
not  often  satisfactory  for  consecutive  work.  For  the  reasons  named,  we 
are  usually  compelled  to  use  artificial  light. 

Laryngoscopy  should  be  practised  with  both  natural  and  artificial 
light,  to  give  familiarity  with  the  appearance  of  the  parts  under  both 
forms  of  illumination.  The  same  larynx  will  have  different  shades 
when  viewed  by  different  lights;  what  appears  congested  when  viewed 
by  artificial  light,  may  seem  of  normal  color  by  daylight. 

For  the  purpose  of  magnifying  the  image  of  the  larynx,  Wertheim  recom- 
mended concave  throat  mirrors,  and  Turck  suggested  a  small  telescope,  some 
improvements  in  which  were  made  by  Voltolini ;  but  these  have  all  been  found 
practically  useless. 

The  laryngoscope  which  I  prefer  consists  of  a  perforated  reflector 
four  inches  in  diameter  (Fig.  58),  with  a  focal  distance  of  eight  inches, 
attached  to  Schrotter's  head  band,  with  nasal  rest,  by  means  of  a  ball- 
and-socket  joint;  with  three  round  throat  mirrors,  three-eighths,  seven- 
eighths,  and  nine-eighths  of  an  inch  in  diameter  respectively,  the  small- 


LARYNGOSCOPY. 


283 


est  for  children,  and  one  oval  mirror  three-fourths  of  an  inch  in  diame- 
ter, for  use  in  cases  of  enlarged  tonsils.  As  before  stated,  these  throat 
mirrors  should  be  backed  with  silver-leaf  and  firmly  fastened  to  an  in- 
flexible stem,  which  may  be  permanently  fastened  to  the  handle  or  not, 
as  is  most  convenient.  The  reflector  need  not  be  more  than  three  and 
one-half  inches  in  diameter,  but  the  larger  instrument  will  reflect  a 
greater  number  of  rays,  and  thus  give  a  somewhat  brighter  illumination. 
The  four-inch  reflector  possesses  the  additional  advantage,  when  worn 
before  one  eye,  of  shading  the  other  from  the  light.  The  only  objection 
I  have  found  to  it  is  that  the  attachment  for  the  ball-and-socket  joint 
is  in  some  instruments  placed  too  far  from  the  perforation,  causing  diffi- 


Fig.  58.— Laryngoscopy  Reflector,  with  attachment  for  holding  lens  co  correct  defective  ac- 
commodation. The  ball  for  ball-and-socket  joint  should  be  placed  accurately  \%  inches  from 
centre  of  reflector. 


culty  in  bringing  the  perforation  squarely  before  the  eye.  This  objec- 
tion should  always  be  remedied  by  the  manufacturer. 

For  an  illuminating  apparatus,  we  may  use  an  Argand  gas-burner  at- 
tached to  a  rack-movement  fixture,  similar  to  the  one  shown  (Fig.  56), 
or  a  German  student's  lamp,  which  may  be  supplemented  by  a  condenser 
(Fig.  57). 

Manipulation  of  the  Laryngoscope. — After  familiarizing  ourselves 
with  the  laryngoscope  and  the  rules  for  its  use,  before  attempting  laryn- 
goscopy on  a  living  subject,  it  is  well  to  practise  for  some  time  on  a 
dummy,  or  on  a  larynx  which  has  been  removed  from  the  body  and 
attached  to  a  standard.  If  one  of  these  cannot  be  obtained,  we  may 
easily  make  a  model  by  boring  a  couple  of  holes  in  a  block  of  wood — 
one  about  two  inches  in  diameter  to  represent  the  mouth,  and  the 
other  about  an  inch  in  diameter,  intersecting  the  first  at  an  angle  of 
eighty  degrees,  to  represent  the  larynx.     By  practising  on  it  we  may 


284 


THE  THROAT. 


familiarize  ourselves  with  the  management  of  the  light,  reflector,  and 
throat  mirror,  and  may  educate  our  hands  to  steadiness. 

Having  learned  to  control  the  hands  so  that  the  mirror  will  not 
tremble,  and  to  reflect  the  rays  of  light  accurately  to  the  objective  point, 
we  may  begin  to  practise  upon  the  living  subject.  A  novice  at  first 
will  find  it  of  great  advantage  to  practise  upon  a  patient  who  has  been 
trained  and  can  undergo  the  manipulations  of  an  unskilled  hand  with- 
out retching  ;  subsequently  he  should  practise  upon  healthy  individ- 
uals for  some  time,  in  order  to  become  so  familiar  with  the  normal 
appearance  of  the  larynx  that  any  deviations  from  it  will  be  at  once 
recognized. 

For  the  most  favorable  laryngoscopic  examination  the  patient 
should  be  seated  in  an  erect  position  with  the   head  thrown  slightly 


Fig.  59.— Position  of  Head  giving  the  Best  View  of  Larynx,  as  shown  in  small  err  at  thb 

LEFT   (ALTERED   FROM    BROWNE). 

back.  The  physician  should  be  seated  in  front  on  the  same  or  on  a 
slightly  higher  level,  and  as  close  as  possible,  with  one  knee  on  either 
side  of  the  patient's  knees,  which  are  brought  together. 

It  is  often  necessary  to  make  the  examination  with  the  patient  slightly 
propped  up  in  bed,  and  the  physician  sitting  as  best  he  may  beside  him  ;  or  with 
the  patient  standing,  as  when  a  library  drop-light  is  used,  which  cannot  be 
brought  low  enough  to  illuminate  the  throat  when  the  patient  is  sitting. 

The  most  suitable  seat  for  the  patient  is  a  narrow  chair,  with  a 
straight  back,  sufficiently  high  to  support  the  head,  and  a  seat  not  more 
than  a  foot  in  depth,  which  will  compel  the  patient  to  sit  erect.  For 
the  physician  a  small  stool,  which  can  be  raised  or  lowered  to  any  de- 
sired level,  is  most  convenient. 


LARYNGOSCOPY. 


285 


The  patient  should  be  seated  beside  or  just  in  front  of  the  table 
which  holds  the  instruments,  with  a  cuspidor  beside  him,  and  a  glass  of 
water  close  at  hand.  If  direct  sunlight  is  employed,  the  patient  should 
be  placed  near  the  window,  facing  the  light,  which,  coming  in  over  the 
physician's  shoulders,  falls  directly  upon  the  pharyngeal  mirror.  With 
reflected  sunlight,  the  positions  of  patient  and  examiner  as  regards  the 
window  are  reversed.  When  artificial  light  is  employed,  the  examining- 
room  should  be  shaded.  The  light  should  be  placed  on  a  level  with  the 
eyes  of  the  patient,  and  slightly  behind  him,  so  that  it  will  not  shine 
on  his  face,  and  about  six  inches  distant  at  one  side,  so  that  the  rays 
may  fall  without  obstruction  on  the  reflector.  If  the  flame  is  much 
above  or  below  the  level  of  the  eyes  of  the  patient,  or  far  from  his  head, 
at  one  side,  the  angle  at  which  the  rays  fall  upon  the  reflector  will  be 
so  great  that  a  good  illumination  will  be  impossible.      The  patient's 


Fig.  60. — Position  of  Head  giving  a  Pooh.  Vifw  of  Larynx,  as  shown  in  the  small  cut  AT 

THE  LEFT  (BROWXE). 

head  should  be  inclined  backward  (Fig.  59),  so  that  the  edge  of  the 
upper  incisor  teeth  will  be  nearly  on  a  horizontal  plane  with  the  poste- 
rior margin  of  the  soft  palate. 

The  reflector  may  be  worn  on  the  forehead,  or  preferably  before  one 
eye.  If  the  lamp  is  on  the  patient's  right,  the  reflector  should  be  placed 
in  front  of  the  examiner's  left  eye,  or  vice  versa.  The  throat  mirror 
may  be  held  in  either  hand,  the  j)atient's  tongue  being  held  by  the  other 
or  by  the  patient  himself.  Eight-handed  persons  should  educate  the 
left  hand  to  the  task  as  soon  as  possible;  for  when  other  instruments 
are  to  be  used,  the  right  hand  will  be  required  for  them.  Even  in 
diagnostic  manipulations  ambidexterity  is  very  desirable,  for  by  hold- 
ing the  mirror  first  with  one  hand  and  then  with  the  other,  any  false 
impressions  of  asymmetry  may  be  corrected. 


286 


THE  THROAT. 


In  making  a  laryngoscopic  examination,  everything  being  in  readi- 
ness, the  physician  takes  his  position  in  front  of  the  patient,  and  fixes 
the  reflector  in  its  place;  his  eve  is  now  brought  within  about  ten  inches 
of  the  patient's  lips,  upon  which  the  light  is  directed.  If  the  lamp  has 
been  placed  at  the  proper  distance,  a  perfect  inverted  image  of  the 
flame  will  be  seen  on  the  patient's  lips:  otherwise  the  light  should  be 
moved  backward  or  forward  until  this  result  is  obtained.     The  patient 


Fig.  61.— The  Laryngoscopic  Mirror  in  Position.  Stem  td  One  Side  (Cohen). 

is  then  directed  to  protrude  his  tongue,  which  the  physician  grasps  and 
holds  between  his  thumb  and  fore-finger,  which  have  been  previously 
enveloped  in  a  soft  napkin.  The  eye  of  the  examiner  is  then  brought 
about  four  inches  nearer,  and  the  light  from  the  reflector  is  so  directed 
that  the  brightest  point  falls  on  the  base  of  the  uvula,  where  it  must  be 
retained.  The  throat  mirror,  having  been  warmed  for  a  moment  over 
the  lamp  and  its  temperature  tested  on  the  cheek  or  back  of  the  hand,  is 
carried  into  position  in  the  throat,  and,  by  a  slight,  steady  movement  of 
the  mirror,  the  image  of  the  larynx  is  brought  into  view  (Fig.  61). 


LARYNGOSCOPY.  287 

The  first  difficulty  which  the  beginner  experiences  is  to  direct  the 
light  into  the  month,  and  the  second  is  to  keep  it  there.  These  difficul- 
ties may  be  readily  overcome  by  practice,  and  should  always  be  mastered 
on  a  dummy  or  some  other  object  before  an  attempt  is  made  to  examine 
a  patient. 

The  patient  should  protrude  the  tongue  as  far  as  possible  by  the 
muscles  of  the  tongue  itself,  and  it  must  be  held  gently  by  the  physician 
without  an  attempt  to  draw  it  farther  out,  for  such  an  attempt  would 
cause  pain  and  contraction  of  its  muscles. 

A  soft  cloth  is  necessary  in  holding  the  tongue,  not  only  for  neatness, 
but  because  if  it  be  grasped  simply  with  the  fingers  it  will  slip  away. 
In  holding  the  tongue,  the  finger  which  is  beneath  it  should  be  held 
slightly  higher  than  the  edge  of  the  lower  teeth,  or  the  teeth  may  be 
covered  by  a  napkin  to  avoid  injury  to  the  frsenum. 

Whenever  both  of  the  physician's  hands  are  to  be  occupied  with  in- 
struments, the  tongue  may  be  held  by  the  patient;  sometimes  this  is  a 
useful  aid  in  overcoming  the  individual's  nervousness. 

The  throat  mirror  employed  must  correspond  to  the  size  of  the 
fauces.  The  one  most  generally  useful  for  adults  is  seven-eighths  of  an 
inch  in  diameter;  but  mirrors  one  and  one-fourth  inches  in  diameter, 
or  even  somewhat  larger,  may  often  be  employed.  The  larger  the 
mirror,  the  better  the  illumination. 

The  mirror  should  be  warmed  so  that  the  moisture  of  the  breath 
may  not  condense  upon  it.  When  first  placed  over  the  flame,  a  thin  film 
will  be  seen  to  spread  over  its  surface,  which  disappears  as  soon  as  the 
glass  becomes  warm.  It  is  then  of  a  proper  temperature  for  use,  but 
should  always  be  tested  on  the  cheek  or  back  of  the  hand. 

Instead  of  warming  the  mirror,  its  surface  may  be  covered  with  a  solution  of 
glycerine  and  water  to  prevent  condensation  of  moisture  ;  this  does  not  leave 
so  good  a  reflecting  surface,  and,  as  a  result,  the  image  will  be  less  distinct. 
Other  devices  have  been  suggested  for  preventing  condensation  of  the  breath  on 
the  mirror,  but  they  are  of  no  practical  value. 

The  mirror  is  less  irritating  to  the  fauces  when  warm,  and  it  will  re- 
tain the  heat  as  long  as  it  ought  to  be  kept  in  the  throat.  It  should  be 
held  like  a  penholder  between  the  thumb  and  fingers,  with  the  hand 
bent  slightly  backward  upon  the  wrist.  It  should  be  passed  horizontally 
into  the  mouth,  with  the  reflecting  surface  downward,  and  carried 
promptly  midway  between  the  tongue  and  the  roof  of  the  mouth,  back 
to  the  uvula,  which  is  caught  upon  it  and  carried  upward  and  backward, 
until  the  rim  of  the  mirror  almost  touches  the  posterior  wall  of  the 
pharynx.  If  the  uvula  hangs  too  low  to  be  easily  caught  on  the  back 
of  the  mirror,  it  may  be  elevated  by  causing  the  patient  to  take  a  deep 
inspiration  or  to  phonate  the  syllable  ah  or  eh.  If  the  throat  will 
tolerate  it,  the  mirror  may  be  rested  against  the  posterior  wall  of  the 
pharynx. 


x!S8  THE  THROAT. 

The  stem  of  the  instrument  may  be  held  either  above  or  at  one  side, 
and  its  handle  should  be  carried  outward  toward  the  angle  of  the  mouth, 
so  that  the  hand  will  not  obstruct  the  light.  The  angle  of  the  mirror 
should  be  about  forty-five  degrees  to  the  plane  of  the  horizon,  though, 
in  practice,  it  will  be  found  that  good  views  can  be  obtained  from  dif- 
ferent points  with  the  mirror  in  various  positions,  by  altering  the  rela- 
tive positions  of  the  physician  and  patient,  or  by  inclining  the  patient's 
head  more  or  less. 

If  the  light  has  been  properly  directed,  it  will  now  fall  on  the  mir- 
ror, whence  it  will  be  more  or  less  perfectly  reflected  into  the  larynx,  an 
inverted  image  of  which  will  be  seen  in  the  mirror  (Fig.  61).  If  the 
view  be  not  perfect,  the  mirror  may  be  slightly  rotated  or  its  obliquity 
altered  by  moving  the  handle ;  but  these  movements  must  be  few  and 
precise,  for  if  many  or  executed  by  an  uncertain,  tremulous  hand,  retch- 
ing is  apt  to  occur. 

Beginners  generally  have  considerable  difficulty  in  this  manipulation 
either  by  losing  the  light  or  by  being  unable  to  obtain  a  view  of  the 
larynx,  on  account  of  an  improper  position  of  the  throat  mirror.  In 
either  case,  the  mirror  should  be  promptly  withdrawn  and  reintroduced, 
for  if  held  in  position  while  the  light  is  being  rearranged,  or  if  moved 
about  in  the  throat  to  secure  another  view,  it  is  likely  to  irritate  the 
fauces. 

With  the  throat  mirror  in  position,  one  will  obtain  a  more  or  less 
perfect  view  of  the  base  of  the  tongue  and  of  the  larynx.  If  only  the 
base  of  the  tongue  or  the  upper  part  of  the  epiglottis  is  brought  into 
view,  depressing  the  handle  slightly  will  expose  the  parts  below;  if 
these  are  first  brought  into  view,  the  superior  structures  may  be  ex- 
posed by  elevating  the  handle.  By  rotating  the  mirror  slowly,  the 
lateral  walls  of  the  pharynx  or  larynx  may  be  exposed. 

To  expose  the  anterior  or  larygneal  surface  of  the  arytenoids,  the 
head  should  be  thrown  slightly  backward  during  a  deep  inspiration,  and 
the  light  should  be  directed  more  posteriorly  than  in  illuminating  the 
cords,  by  holding  the  throat  mirror  more  nearly  horizontal.  To  expose 
their  posterior  or  pharyngeal  surface,  the  head  should  be  nearly  erect, 
and  the  mirror  should  be  held  as  just  directed  while  the  voice  is  sounded. 

To  examine  either  side,  the  mirror  should  be  placed  partly  upon  the 
opposite  side  of  the  fauces,  with  its  obliquity  changed  so  as  to  illuminate 
the  parts  to  be  inspected. 

In  order  to  obtain  a  good  view  of  the  laryngeal  surface  of  the  epi- 
glottis, the  patient  should  be  directed  to  sound  a  high  note  quickly  and 
with  considerable  force.  This  throws  the  cartilage  upward  with  a  sud- 
den jerk.  An  inspiration  accompanied  with  sound  or  an  ironical  laugh 
will  answer  the  same  purpose. 

The  hand  which  holds  the  mirror  may  be  steadied  by  resting  the 
ring  and  little  fingers  on  the  patient's  cheek. 


OBSTACLES   TO  LARYNGOSCOPY.  289 

The  mirror  should  not  be  kept  in  the  throat  more  than  twenty  or 
thirty  seconds,  but  the  examination  may  be  continued  by  reintroducing 
it  several  times. 

Whenever  the  slightest  indication  of  retching  occurs,  the  mirror 
must  be  instantly  withdrawn,  but,  after  a  few  moments,  another  trial 
may  be  made,  which  the  patient  will  usually  tolerate  as  well  as  the  first. 

When  inserting  the  mirror,  its  reflecting  surface  should  not  touch 
the  tongue,  nor  its  back  rub  against  the  palate.  The  former  accident 
clouds  the  reflecting  surface,  and  either  is  likely  to  cause  retching  or 
an  attempt  to  swallow,  which  will  prevent  the  examination. 

OBSTACLES    TO    LARYNGOSCOPY. 

The  obstacles  frequently  encountered  in  laryngoscopy  can  usually  be 
overcome  by  a  little  tact  and  patience,  at  least  at  a  second  sitting.  We 
should  not  expect  a  thorough  view  of  the  larynx  without  introducing 
the  mirror  two  or  three  times;  though,  if  the  patient's  throat  is  not 
sensitive,  by  rotating  the  mirror  slightly  the  entire  larynx  may  some- 
times be  inspected  with  a  single  introduction  of  the  mirror. 

The  principal  obstacles  to  be  overcome  are :  an  elongated  uvula,  en- 
larged tonsils,  irritable  fauces,  a  short  frasnum,  arching  upward  of  the 
back  of  the  tongue,  and  a  pendent  epiglottis.  In  two  cases,  one  an 
actor,  and  the  other  an  elocutionist,  I  have  found  difficulty  in  inspecting 
the  larynx  apparently  on  account  of  hypertrojdiy  of  the  lingual  muscles, 
which  greatly  restricted  the  space  between  the  tongue  and  the  posterior 
wall  of  the  pharynx. 

An  elongated  uvula,  hanging  below  the  mirror,  appears  as  though 
curled  over  the  lower  edge  and  resting  upon  the  reflecting  surface.  This 
is  very  confusing  and  prevents  a  view  of  the  parts  below. 

To  obviate  this  difficulty  in  ordinary  cases,  it  is  only  necessary  to  use 
a  large  mirror  and  to  be  careful  in  placing  it  against  the  uvula.  Mir- 
rors have  been  devised  with  a  little  pocket  in  the  back  for  catching  the 
uvula,  but  they  are  now  rarely  if  ever  used.  If  the  uvula  is  so  long  that 
it  cannot  be  managed  with  a  large  mirror,  it  may  be  contracted  by  as- 
tringents; if  these  are  inadequate,  it  should  be  amputated  and  the  ex- 
amination made  at  a  subsequent  sitting. 

On  account  of  irritable  fauces  some  patients  cannot  bear  simple 
Inspection  of  the  mouth  without  gagging  or  retching;  others  are  so  af- 
fected when  the  tongue  is  protruded ;  still  others  as  soon  as  the  throat 
mirror  touches  the  fauces. 

To  overcome  these  difficulties,  the  patient  should  be  fully  impressed 
with  the  necessity  of  the  examination,  and  urged  to  restrain  himself 
from  retching;  the  mirror  should  then  be  introduced  during  a  deep 
inspiration  or  as  the  patient  says  eh  or  ah,  which  elevates  the  uvula, 
and,  by  thus  preventing  the  necessity  for  pressure  against  the  palate, 
secures  nauch  greater  tolerance  of  the  instrument. 
T9 


200  THE  THROAT. 

"With  nervous  patients  it  is  often  best,  for  the  sake  of  first  gaining 
their  confidence,  to  introduce  the  mirror  once  or  twice  so  as  just  to 
touch  the  palate,  and  then  withdraw  it  at  once  without  attempting  to 
see  the  larynx.  Ice  may  be  sucked  for  fifteen  or  twenty  minutes,  to 
produce  some  degree  of  temporary  local  anaesthesia.  If  these  devices 
fail,  the  most  feasible  method  for  overcoming  the  disposition  to  retching 
is  an  application  a  few  times  of  a  small  amount  of  a  ten-per-cent  solu- 
tion of  cocaine,  by  spray. 

Many  persons,  in  whom  the  pharynx  is  sensitive,  will  tolerate  an 
examination  at  a  second  or  third  sitting,  in  whom  hardly  a  glimpse  could 
be  obtained  at  the  first.  In  such  cases  it  is  a  good  plan  to  have  the 
patient  educate  the  throat  to  bear  instruments,  by  introducing  a  spoon- 
handle  against  the  uvula  before  a  mirror  several  times  daily  during  the 
interim. 

In  cases  of  irritability  of  the  fauces,  some  laryngologists  recommend  titilla- 
tion  of  the  palate  with  a  probe  or  a  penholder  before  attempting  to  introduce 
the  mirror,  in  order  that  the  parts  may  become  accustomed  to  manipulation. 
Various  other  devices  have  been  recommended  for  overcoming  the  sensitiveness 
such  as  painting  the  fauces  with  chloroform  and  morphine,  inhalation  of  a  few 
whiffs  of  chloroform,  and  the  internal  use  of  large  doses  of  potassium  bromide  ; 
but  none  of  these  measures  are  very  satisfactory.  Ordinarily  we  will  succeed 
best  simply  by  patience  and  care  in  introducing  and  holding  the  mirror,  supple- 
mented, when  necessary,  by  the  use  of  ice  or  cocaine.  The  fauces  are  more 
irritable  when  the  stomach  is  disordered  and  during  digestion  than  at  other 
times;  therefore  it  is  best,  whenever  the  throat  is  sensitive,  to  make  the  exami- 
nation before  eating  or  not  until  three  or  four  hours  afterward. 

A  short  fr.esum  is  one  of  the  minor  obstacles.  If  it  proves  very 
troublesome,  it  may  be  cut  witli  a  pair  of  blunt-pointed  scissors. 

Archixg  of  the  toxgue  occurs  in  some  patients  just  as  the  mir- 
ror is  being  carried  between  the  teeth,  the  posterior  part  of  the  tongue 
arching  upward,  so  as  to  touch  the  soft  palate,  and  thus  preventing  the 
passage  of  the  mirror  into  the  fauces;  or  remaining  here  to  intercept 
the  rays  of  light  after  the  mirror  is  in  position.  This  difficulty  is  best 
overcome  by  cautioning  the  patient  not  to  strain  and  by  care  not  to 
draw  the  tongue  far  out  of  the  mouth  or  downward  toward  the  chin. 

Sometimes  a  good  view  of  the  larynx  can  be  obtained  in  these  in- 
stances by  holding  the  throat  mirror  nearly  horizontally  against  the  palate, 
and  reflecting  the  light  upon  it  from  below  upward.  In  some  cases,  the 
patient,  by  watching  the  movements  of  his  tongue  in  a  hand  mirror, 
may  be  able  to  keep  its  base  depressed.  Other  patients  will  need  to 
practise  before  a  mirror  at  home  for  several  days  before  control  of  the 
organ  can  be  obtained.  Tongue  depressors  seem  indicated  in  these  cases, 
but  are  of  little  value. 

Greatly  enlarged  toxsils  may  prevent  the  introduction  of  any 
mirror  into  the  throat;  in  such  cases  the  only  remedy  is  excision.    When 


OBSTACLES  TO  LARYNGOSCOPY. 


291 


they  are  only  moderately  enlarged,  it  will  sometimes  be  impossible  to 
introduce  the  ordinary  mirror  without  touching  them  both,  and  perhaps 
causing  retching;  but  in  many  cases,  if  the  mirror  is  carried  promptly 
between  and  behind  the  tonsils,  the  throat  will  remain  quiet,  even 
though  both  sides  have  been  touched.  In  other  cases  it  is  best  to  use  an 
oval  mirror,  which  may  be  passed  into  the  fauces  without  touching  the 
tonsils. 

A  laege  or  pendent  epiglottis  is  sometimes  an  insurmountable 
obstacle  to  laryngoscopy.  When  the  glosso-epiglottidean  ligaments  are 
relaxed,  or  when  the  epiglottis  is  swollen,  it  falls  downward,  so  that  its 


Fig.  62. — Bkuns'  Pincette 

free  edge  may  rest  against  the  pharyngeal  wall,  leaving  little  if  any 
space  for  the  passage  of  light.  In  some  of  these  cases  we  can  obtain  a 
view  of  the  larynx  by  causing  the  patient  to  sound  the  letter  e  in  a 
high  key  or  to  utter  a  high  falsetto  note.  A  vocal  sound,  as  ah  or 
eh  made  during  inspiration,  will  have  a  similar  effect.  By  a  laugh 
or  a  cough  the  epiglottis  may  be  thrown  upward  with  a  sudden  jerk.  In 
other  instances  it  is  only  necessary  for  the  patient  to  drawn  a  deep 
breath  in  order  to  raise  the  epiglottis  sufficiently  to  give  a  view  beneath 
it.  Frequently  by  passing  the  mirror  lower  into  the  pharynx,  and  more 
perpendicularly  than  usual,  the  inferior  surface  of  the  epiglottis  and 
other  portions  of  the  larynx  may  be  seen. 

Various  instruments  have  been  devised 
for  lifting  the  epiglottis.  The  best  of  these 
is  known  as  Voltolini's  staff,  a  stout  whale- 
bone or  metallic  rod,  bent  nearly  to  a  right 
angle  about  an  inch  from  the  end,  with  its 
terminal  extremity  turned  slightly  backward. 
It  may  be  passed  behind  the  lip  of  the  epi- 
glottis, so  as  to  lift  and  draw  it  forward. 

Occasionally  when  operations  are  to  be 
performed,  or  for  simple  inspection,  some 
special  instrument  may  be  necessary  to  hold 
the  lip  of  the  epiglottis  forward.  For  this 
purpose  Bruns'  pincette  has  been  recom- 
mended. Instruments  of  this  kind,  how- 
ever, usually  cause  too  much  irritation  to  be 
tolerated,  and  a  simple  bent  staff  or  strong  probe  will  be  found  preferable. 

It  occasionally  happens  that  only  the  posterior  part  of  the  larynx  can 
be  seen,  and  the  vocal  cords  cannot  be  brought  into  view.     In  such  in- 


Fig.  63.— Infra-glottic  Laryn- 
goscopy Small  metallic  mirror 
in  position  in  the  fenestra  of  the 
tracheal  canula. 


292  THE  THROAT. 

stances  the  movements  of  the  arytenoid  cartilages  may  be  seen  suffi- 
ciently to  enable  us  to  judge  of  the  mobility  of  the  cords;  but  the  ap- 
pearance of  the  tissue  covering  them  is  not  an  accurate  indication  of  the 
condition  of  the  mucous  membrane  in  other  portions  of  the  larynx. 

INFKA-G  LOTTIC    LARYNGOSCOPY. 

It  is  sometimes  desirable  to  inspect  the  larynx  from  below,  which 
may  be  done,  after  tracheotomy,  through  a  fenestra  in  the  canula,  by 
the  aid  of  a  small  metallic  mirror  (Fig.  63). 


CHAPTER   XVII. 

DISEASES  OF   THE   THEOAT.— Continued. 

THE   LARYNX  AND  RHINOSCOPY. 

The  image  of  the  larynx,  as  seen  in  the  throat  mirror,  is  reversed,  so 
that  the  anterior  portion,  nearest  the  observer,  appears  in  the  glass  above 
and  farthest  from  its  surface,  the  portion  normally  posterior  appearing 


Fig.  64. 


Fis.  65. 


Fig.  64. — Relative  Positions  of  Larynx  and  its  Image  in  the  Laryngoscopy  Mirror 
(Cohen). 

Fig.  65.— Normal  Larynx  in  Respiration,  enlarged.  Parts  exaggerated  to  render  them  more 
conspicuous.  1,1,  Lingual  surface  of  epiglottis  ;  2, 2,  laryngeal  surface  of  epiglottis  ;  3,  indented  crest 
of  epiglottis  ;  4.  4,  pharyngo-epiglottic  folds  ;  5,  5.  ary-epiglottic  folds  ;  6,  cushion  of  epiglottis  ;  7. 
glosso-epiglottic  ligament ;  8,  8,  valeeulas  ;  9,  9,  pyriform  sinuses  ;  10,  10,  posterior  pharyngeal  wall 
and  entrance  into  oesophagus  ;  11,  inter-arytenoid  incisure  ;  12, 12,  cartilages  of  Santorini  ;  13,  inter- 
arytenoid  fold  ;  14,  14,  cartilages  of  Wrisberg  ;  15.  15.  ventricular  bands  ;  16, 16,  vocal  cords  ;  17, 17, 
ventricles  :  18,  18,  posterior  vocal  processes  ;  19,  thyroid  cartilage  ;  20.  crico-thyroid  membrane  ;  21, 
cricoid  cartilage  ;  22,  22.  22,  rings  of  trachea  ;  23,  23,  23,  23,  interspaces  between  rings  of  trachea 
(Cohen). 

below  close  to  the  lower  edge  of  the  mirror.     The  sides  of  the  larynx 
are  not  reversed  in  the  image. 

An  image  of  the  whole  larynx  can  seldom  be  obtained  at  a  single 
glance;  but  by  slight  rotation  of  the  mirror,  with  elevation  and  depres- 
sion of  the  handle,  so  as  to  alter  the  plane  of  the  reflecting  surface,  the 
different  parts  may  be  brought  into  view.     The  vocal  cords,  because  of 


THE  THROAT. 

their  white  appearance  and  frequent  respiratory  movements,  naturally 
attract  the  most  attention,  and  when  once  seen  can  hardly  be  forgotten; 
but  the  epiglottis  comes  first  into  view. 

The  normal  larynx  is  shown  in  a  somewhat  exaggerated  form 
(Fig.  65)  in  order  that  the  parts  may  be  more  clearly  identified. 

The  epiglottis  is  a  leaf-like  valve,  which  covers  the  upper  opening 
of  the  larynx  and  closes  it  during  deglutition. 

The  base  of  the  epiglottis — in  reality  the  apex  of  the  cartilage — 
is  connected  with  the  thyroid  cartilage  at  its  receding  angle  by  a  long 
narrow  band,  known  as  the  thyro-epiglottic  ligament;  a  small  band,  the 
hyo-epiglottic  ligament,  connects  it  with  the  posterior  surface  of  the 
hyoid  bone.  The  free  extremity  is  broad  and  rounded.  The  lingual  or 
upper  surface  of  this  oartilage  usually  curves  forward,  its  concavity 
toward  the  base  of  the  tongue.  Its  covering  of  mucous  membrane  forms 
a  median  and  two  lateral  folds,  known  as  the  glosso-epiglottic  folds. 
The  central  one  of  these  is  also  called  the  frsenum  of  the  epiglottis,  or 
the  glosso-epiglottic  ligament  as  it  contains  a  ligamentous  band.  The 
lateral  folds  contain  no  fibrous  tissue  and  are  frequently  absent.  The 
laryngeal  or  inferior  surface  curves  in  a  reverse  direction.  It  is  convex 
from  above  downward,  and  concave  from  side  to  side.  To  its  sides  are 
attached  the  pharyngo-epiglottic  and  the  ary-epiglottic  folds. 

It  varies  greatly  in  size  and  form  in  different  individuals  (Figs.  66  to 
71).  It  may  be  long  and  thin,  or  short  and  thick;  it  may  be  broad,  or 
narrow  and  pointed ;  its  free  edge  may  be  curved  like  a  bow,  it  may  be 
folded  in  upon  itself  like  a  scroll  in  what  is  known  as  the  jews-harp 
form  (Fig.  TO),  or  it  may  be  asymmetrical.  It  may  cover  the  whole 
larynx,  or  it  may  be  nearly  invisible.  Sometimes  only  the  upper  or  an- 
terior surface  of  the  epiglottis  can  be  seen,  at  other  times  its  lower  por- 
tion or  laryngeal  surface  is  most  visible;  again,  only  its  tip  is  brought 
into  view;  and  still  again  considerable  portions  of  both  the  anterior  and 
the  posterior  surfaces  may  be  seen  at  the  same  time. 

With  respiration,  the  lip  of  the  epiglottis  rises  and  falls  slightly. 
With  phonation  it  is  generally  thrown  upward,  and  in  deglutition  it  is 
carried  downward  to  the  posterior  border  of  the  larynx. 

The  whole  epiglottis  is  seldom  visible  even  to  a  skilful  laryngologist. 
Usually  a  portion  of  its  upper  surface  is  visible  on  each  side.  In  the 
middle,  its  laryngeal  surface  is  turned  upward  like  a  lip,  and  below  this 
a  small  prominence  may  frequently  be  seen  near  the  base  of  the  epiglot- 
tis, known  as  its  cushion,  pad,  or  protuberance  (Fig.  68). 

The  color  of  this  organ  varies  in  different  parts.  The  upper  surface 
is  of  a  pinkish  hue,  and  frequently  blood-vessels  may  be  seen  crossing 
it.  The  lip  looks  like  a  yellow  cartilage,  as  it  really  is,  covered  with 
mucous  membrane.  The  cushion  generally  appears  of  a  much  brighter 
red  color  than  other  portions  of  the  e])iglottis.  When  the  whole  of  the 
laryngeal  surface  can  be  seen,  it  often  has  a  uniform  bright-red  color, 


THE  LARYNX. 


295 


which  might  be  easily  mistaken  for  congestion.  When  only  the  edge  of 
the  epiglottis  is  visible,  it  appears  like  a  pale  whitish  line  just  beneath 
the  base  of  the  tongue. 

The  vallecula,  upon  either  side  of  the  fraenum  of  the  epiglottis, 
are  two  sinuses  known  also  as  the  lingual  sinuses,  closely  resembling  de- 
pressions, such  as  might  be  made  by  pressing  the  tips  of  two  fingers  into 


Fig.  60. 


Fig.  68. 


Fig.  70. 


Fig.  71. 


Figs.  66  to  71.—  Normal  Larynx,  showing  Various  Forms  of  Epiglottis  and  Supra-aryte- 
noid  Cartilages. 

Fig.  66. — Pitcher-shaped  Inter- arytenoid  Fold,  Phonation. 

Fig.  67. — Lapping  of  Arytenoid  Cartilages  in  Phonation,  with  Gaping  of  Vocal  Cords. 

Fig.  68. — Cushion  of  Epiglottis  Visible  ;  no  Gaping  of  Vocal  Cords  in  Phonation 
(Ziemssen). 

Fig.  69. — Pointed  Epiglottis;  Ventricles  Distinct;  Inspiration. 

Fig.  70.— "'Jews-harp1'  or  Omega-like  Epiglottis. 

Fig.  71.— Female  Larynx  in  Respiration  (Cohen). 

The  female  larynx  may  have  the  form  shown  in  any  of  the  preceding  figures. 

some  plastic  substance  (Fig.  65).  They  vary  greatly  in  depth  and  in  width 
in  different  individuals,  and  in  various  positions  of  the  epiglottis  in  the 
same  individual.  These  sinuses  should  always  be  examined  as  they 
frequently  give  lodgement  to  portions  of  food  which  are  a  source  of  irri- 
tation, and  they  are  sometimes  the  seat  of  ulcers. 
19  " 


296  THE  THROAT. 

The  akytenoid  cartilages — so  named  on  account  of  their  appar- 
ent resemblance  during  phonation  to  the  nose  of  a  jjitcher — appeal  be- 
neath the  free  edge  of  the  epiglottis.  They  are  two  in  number,  one 
upon  each  side.  They  are  located  at  the  back  of  the  larynx,  resting 
upon  the  upper  border  of  the  cricoid  cartilage.  Each  of  these  cartilages 
is  somewhat  pyramidal.  The  apex,  which  is  slightly  pointed  and  curved 
upward  and  inward,  is  surmounted  by  a  small  conical  nodule,  which  has 
been  named  the  corniculum  laryngis  or  cartilage  of  Santorini. 

The  cartilages  of  Santorini,  which  are  usually  about  the  size 
of  a  millet  seed,  are  most  prominent  when  the  glottis  is  closed,  as  in 
phonation.  The  mucous  membrane  immediately  covering  their  apices 
is  of  a  lighter  hue  than  that  in  other  parts  of  the  larynx,  but  the  light 
color  is  usually  surrounded  by  a  zone  of  deeper  red. 

The  cartilages  of  Wrisberg  are  just  external  to  the  cartilages  of 
Santorini,  in  the  fold  of  mucous  membrane  which  extends  on  either  side 
to  the  edge  of  the  epiglottis,  prominences  known  also  as  the  cuneiform 
cartilages. 

These  cartilages  vary  considerably  in  form  in  different  individuals. 
They  are  usually  round,  but  are  occasionally  triangular,  the  apices  being 
directed  downward.  Sometimes  they  are  hardly  visible,  but  they  are  gen- 
erally quite  distinct  and  fully  as  large  as  the  cartilages  of  Santorini. 
These,  like  the  cornicula,  are  of  a  lighter  color  than  the  folds  which 
contain  them,  but  they  are  usually  surrounded  by  a  zone  of  mucous 
membrane  redder  than  the  general  surface. 

In  a  few  instances  a  small  nodule,  due  to  a  third  cartilage,  is  seen 
between  the  cartilages  of  Wrisberg  and  the  cartilages  of  Santorini  on 
each  side.  The  cartilages  of  "Wrisberg  and  those  of  Santorini  are  some- 
times termed  the  supra-arytenoid  cartilages. 

The  arytexo-epiglottidean  folds  or  the  ary-epiulottic  folds 
constitute  the  lateral  and  part  of  the  posterior  border  of  the  superior 
opening  of  the  larynx.  They  consist  of  folds  of  mucous  membrane,  one 
on  each  side,  which  extend  like  bows  from  the  arytenoid  cartilages  up- 
ward and  forward  to  the  sides  of  the  epiglottis.  They  are  usually  from 
one-twelfth  to  one-eighth  of  an  inch  in  thickness,  but  are  occasionally  thin 
and  sharp.  In  color  they  closely  resemble  the  gums,  and  are  somewhat 
lighter  than  the  zones  about  the  bases  of  the  supra-arytenoid  cartilages. 

The  pyramidal,  pyriforii,  or  laryngopharyngeal  sinuses  are 
found  external  to  the  folds  just  named,  and  between  them  and  the  wings 
of  the  thyroid  cartilage.  The  broad  end  of  each  sinus  is  directed  for- 
ward, and  its  apex  backward.  It  is  bounded  internally  by  the  quad- 
rangular membrane,  the  upper  border  of  which  is  formed  by  the  ary- 
epiglottic  fold,  anteriorly  by  the  wing  of  the  thyroid  cartilage,  and 
laterally  by  the  wall  of  the  pharynx.  Like  the  valecula?,  these  sinuses 
often  give  lodgement  to  foreign  bodies,  and  are  frequently  the  seat  of 
ulcerations. 


THE  LARYNX.  297 

The  ventricular  bands,  known  also  as  the  superior  or  false  vocal 
cords,  the  regulators  of  the  glottis,  or  the  superior  ligaments  of  the 
larynx,  are  thick  folds  of  mucous  membrane  which  stretch  across  the 
larynx  in  an  antero-posterior  direction,  about  half  an  inch  below  its 
superior  opening  and  a  short  distance  above  the  true  vocal  cords.  They 
are  frequently  very  prominent,  standing  out  in  thick  welts  from  the 
sides  of  the  larynx.  In  other  instances,  they  can  hardly  be  distin- 
guished from  the  surrounding  tissues.  They  are  of  a  deeper  red  color 
than  the  tissues  above  them,  but  their  inferior  or  inner  borders  gen- 
erally appear  pale  in  the  laryngoscopic  image,  on  account  of  being  illu- 
minated more  perfectly  than  the  surrounding  parts.  Just  beneath  the 
anterior  ends  of  the  false  vocal  cords  and  above  the  true  cords  may  fre- 
quently be  seen  a  fossa,  about  the  size  of  a  pin's  head  which  has  been 


Fig.  72.— View  of  Left  Side  of  Larynx  (Turck).  a,  Left  vocal  cord  ;  b,  posterior  portion  of 
ventricle  ;  c,  left  ventricular  band  ;  d,  posterior  surface  of  epigloteis ;  e,  border  of  ary-epiglottic 
fold  ;  /,  left  cartilage  of  Wrisberg  ;  g,  right  cartilage  of  Wrisberg  ;  h,  right  vocal  cord. 

named  by  Mackenzie  the  fossa  innominata.  This  communicates  with 
the  laryngeal  sinuses  upon  either  side. 

The  ventricles  of  the  larynx  are  found  immediately  beneath 
the  ventricular  bands.  These  consist  on  either  side  of  an  oblong  fossa, 
which  is  the  opening  to  a  cul  de  sac  of  mucous  membrane,  known  as  the 
sacculus  laryngis.  They  are  bounded  above  by  the  false  vocal  cords; 
below,  by  the  true  vocal  cords;  and  externally,  by  the  thyro-arytenoid 
muscles. 

The  ventricles  are  seldom  seen,  and,  when  visible,  usually  appear 
merely  as  dark  lines ;  but  occasionally  they  are  patulous,  with  a  width  of 
nearly  one-eighth  of  an  inch. 

The  sacculus  laryngis  extends  upward  and  outward  in  a  conical 
form  beneath  the  ventricular  band.  The  mucous  membrane  lining  it  is 
studded  with  the  openings  of  sixty  or  seventy  follicular  glands,  the  secre- 
tion from  which  is  apparently  intended  for  lubricating  the  vocal  cords. 
This  pouch  is  covered  by  a  fibrous  membrane,  and  this  membrane  by 
muscular  tissue,  which,  according  to  Hilton,  compresses  the  sacculus  and 
discharges  its  secretion  upon  the  vocal  cords. 

The  vocal  cords,  known  also  as  the  inferior  or  true  vocal  cords,  are 
the   most  important   objects  to  be  seen  on  inspection  of  the  larynx. 


298 


THE  THROAT. 


They  appear  as  two  pearly  white  bands  stretched,  one  along  each  side  of 
the  larynx  from  its  anterior  to  its  posterior  part. 

In  the  adult  they  vary  from  five-eighths  of  an  inch  to  one  inch  in 
length,  and  are  usually  about  one-eighth  of  an  inch  in  breadth;  they  are 
sometimes  perfectly  white  in  women,  but  in  men  they  are  usually  of  a 
yellowish  white  hue.  They  consist  of  fibrous  bands  covered  by  a  thin 
layer  of  closely  adherent  mucous  membrane,  being  attached  anteriorly 
to  a  depression  between  the  alae  of  the  thyroid  cartilage,  posteriorly  to 
the  anterior  angles  at  the  base  of  the  arytenoid  cartilages. 

During  respiration  the  cords  alternately  approach  each  other  and 
recede,  leaving  between  them  a  triangular  opening  for  the  passage  of  air. 
The  cords  and  the  space  between  them  form  what  is  known  as  the  glot- 
tis.    The  free  edges  constitute  the  lips  oi  the  glottis,  and  the  chink  or 


Fig.  73.— Normal  Larynx  of  Woman  in  Formation  of  Head  Tones  (Cohen). 


fissure  between  them  is  called  the  rima  glottidis.  The  front  of  the 
rima  is  formed  by  the  anterior  commissure  of  the  vocal  cords,  its  sides  by 
the  cords  themselves,  and  its  base  by  the  arytenoid  cartilages  and  the 
inter-arytenoid  fold.  In  the  adult,  this  fissure  varies  in  length  from 
seven  to  ten  lines  in  women,  and  from  ten  to  thirteen  in  men.  At  its 
widest  part  it  ordinarily  measures  from  three  to  six  lines,  but  on  deep 
inspiration  it  may  measure  as  much  as  eight  or  ten  lines.  In  children, 
it  is  of  course  much  smaller. 

On  inspiration,  the  cords  separate  widely  at  their  posterior  extremi- 
ties; but  their  anterior  extremities  remain  close  together,  thus  forming 
a  triangular  opening.  On  expiration  they  approach  more  nearly  together, 
and  in  phonation  their  two  borders  are  more  or  less  closely  approximated, 
but  there  is  usually  a  narrow  fissure  between  them  throughout  their  en- 
tire length.  In  women,  and  occasionally  in  men,  during  the  production 
of  head  tones,  the  vocal  processes  are  pressed  firmly  together,  so  that  the 
fissure  is  left  only  between  the  anterior  parts  of  the  cords. 

From  a  careful  photographic  study  of  the  larynx  during  the  produc- 
tion of  the  singing  voice,  Thomas  R.  French  (Transactions  of  American 
Laryngological  Association,  1888)  concludes  that  the  female  voice  has 
three  and  the  male  voice  two  registers;  the  transition  from  one  to  the 
next  higher  being  usually  marked  by  backward  movement  of  the  epi- 


THE  LARYNX.  299 

glottis,  change  in  the  shape  of  the  glottis,  shortening  of  the  cords,  and 
an  apparent  increase  in  their  tension.  Protrusion  of  the  tongue  does 
not  materially  affect  the  laryngoscopic  appearance. 

The  cords  are  sometimes  lengthened  in  men  on  changing  to  a  higher  register. 

The  processus  yocales  or  vocal  processes  are  sometimes  seen  as 
four  yellowish  spots,  two  anteriorly  and  two  posteriorly,  where  the  vocal 
cords  are  attached  to  the  cartilages,  but  the  anterior  processes  are  not 
often  visible.  Usually,  when  we  speak  of  the  vocal  processes,  simply  the 
anterior  angles  of  the  arytenoid  cartilages  are  referred  to.  Carl  Seiler 
has  described  narrow  fusiform  cartilages,  found  along  the  edge  of  the 
vocal  cords  in  women.     These  are  only  rudimentary  in  men. 

The  lnter-arytexoid  fold  or  posterior  commissure  is  a  band  of 
mucous  membrane  which  extends  between  the  arytenoid  cartilages.  The 
prominence  of  this  fold  depends  upon  the  position  of  the  cartilages. 
When  the  glottis  is  open,  it  may  measure  six  or  eight  millimetres  in 
length;  but  when  the  cords  are  approximated,  it  is  folded  upon  itself  so 
that  it  can  hardly  be  seen. 

The  cricoid  cartilage  may  usually  be  seen  a  short  distance  below 
the  vocal  cords,  separated  from  their  anterior  extremities  by  the  lower 
portion  of  the  thyroid  cartilage  and  by  the  crico-thyroid  membrane. 
This  cartilage  is  of  a  lighter  hue  than  the  membranous  tissue  above  or 
below  it,  and  is  similar  in  color  to  the  rings  of  the  trachea. 

The  tracheal  cartilages  or  rings  of  the  trachea  are  usually  visible, 
arching  across  this  tube  from  side  to  side  with  their  concavities  directed 
inward  and  downward.  The  upper  of  these  rings  are  very  distinct  and 
of  a  yellowish  or  a  light  pinkish  hue.  They  are  separated  from  each 
other  by  the  intervening  membranous  tissue,  which  is  of  a  darker  color. 

As  we  carry  the  inspection  farther  down  the  trachea,  the  cartilages 
appear  narrower  and  narrower  until  their  outlines  are  finally  lost. 

The  mucous  membrane  lining  the  trachea  is  generally  paler  than  that 
covering  the  surface  of  the  larynx. 

Considerable  variety  in  the  shape  and  movements  of  different  parts 
of  the  larynx  may  occur  within  the  limits  of  health.  This  is  especially 
the  case  with  the  epiglottis;  and  variations  in  the  appearance  of  the  ary- 
tenoid cartilages  and  of  the  commissures,  and  slight  alterations  in  other 
parts  of  the  larynx  may  occasionally  be  found,  as  illustrated  in  Figs.  66 
to  71.  The  epiglottis  may  possess  any  of  the  various  forms  already 
spoken  of.  The  supra-arytenoid  cartilages  vary  considerably  in  their 
size  and  form,  as  already  mentioned.  The  position  of  the  arytenoids 
varies  constantly  with  respiration  and  phonation,  and  may  be  quite  dif- 
ferent in  healthy  individuals  (Figs.  66  to  71). 

In  disease  of  the  larynx,  changes  in  its  form  and  movements  consti- 
tute the  principal  signs.  There  may  be  hypertrophy  or  swelling  of  its 
various  parts,  with  more  or  less  loss  of  movement,  or  ulceration  may 


THE   THROAT. 


have  destroyed  more  or  less  of  the  tissues.  Sometimes  the  epiglottis  is 
eo  swollen  and  wrinkled  as  to  be  hardly  recognizable;  its  free  edge  may 
be  ulcerated,  or  the  cartilage  may  be  partly  or  entirely  destroyed  by  the 
same  process.  Swelling  of  the  inner  extremity  of  the  ary-epiglottic 
folds  and  of  the  tissues  surrounding  the  arytenoid  cartilages  is  fre- 
quently found  upon  one  or  both  sides.  Loss  of  movement  occurs  from 
cicatricial  adhesions  or  paralysis.  Morbid  growths  are  of  comparatively 
frequent  occurrence. 

EXAMINATION    OB    THE    TRACHEA. 

In  order  to  obtain  a  good  view  of  the  trachea,  it  is  usually  necessary 
to  hold  the  mirror  more  nearly  horizontal  than  in  the  examination  of 
the  larynx,  so  as  to  reflect  the  light  somewhat  more  posteriorly.  The 
glottis  must  be  widely  opened,  and  the  focal  point  of  the  light  must  fall 


Fig.  74.— View  of  Posterior  Wall  of  Tra- 
chea and  Bronchi,  bs.  Bifurcation  of  trachea  ; 
sg,  subglottic  region  ;  p,  posterior  wall  of  tra- 
chea (Mackenzie). 


Fig.  To.— View  of  Anterior  Wall  of  Tra- 
chea and  Bronchi,  at.  Anterior  wall  of  tra- 
chea :  /'■'■.  tec,  vocal  cords  ;  rb,  right  bronchus  ; 
lb.  left  bronchus  :  bs,  bifurcation  or  bronchial 
spur  i  Mackenzie 


upon  the  parts  to  be  examined;  that  is,  at  a  distance  of  from  seven  to 
eleven  inches  within  the  lips,  or  from  twelve  to  seventeen  inches  from 
the  reflector,  according  to  the  portion  of  the  tube  to  be  examined. 
Sometimes  we  can  obtain  a  good  view  by  elevating  the  patient  to  a  plane 
above  that  of  the  observer,  and  holding  the  throat  mirror  almost  hori- 
Lontal  so  that  the  light  may  be  thrown  upon  it  from  below  upward. 

To  expose  the  posterior  wall  of  the  larynx  and  the  trachea,  the 
patient's  head  should  be  kept  erect,  and  the  mirror  held  in  a  nearly  hor- 
izontal position. 

With  a  good  light  and  a  favorable  condition  of  the  larynx  and  trachea, 
the  openings  of  the  main  bronchi  can  frequently  be  seen,  and  in  some 
instances  a  few  of  their  cartilaginous  rings  may  be  counted.  To  illu- 
minate the  bifurcation  of  the  trachea,  a  good  plan  is  first  to  obtain  a 
view  of  the  laryngeal  surface  of  the  epiglottis,  and  then,  by  gradually 
changing  the  obliquity  of  the  mirror,  direct  the  rays  farther  and  farther 
downward  along  the  anterior  surface  of  the  trachea  until  the  deeper 
parts  are  brought  into  view, 


ANTERIOR  RHINOSCOPY. 


301 


RHINOSCOPY. 

Khinoscopy  or  examination  of  the  nasal  cavities  is  termed  anterior  or 
posterior  according  to  the  position  of  the  parts  inspected. 


ANTERIOR    RHINOSCOPY. 


Anterior  rhinoscopy  or  the  inspection  of  the  anterior  nares  is  per- 
formed with  the  aid  of  the  laryngoscopic  reflector  and  a  nasal  speculum. 
Various  instruments  have  been  made  for  the  purpose.     A  simple  bivalve 


Fig.  76.— Ingals'  Nasal  Speculum  (3-5  size). 

speculum,  such  as  shown  in  Fig.  76,  is  most  satisfactory  for  purposes  of 
diagnosis;  but  when  operations  are  to  be  performed,  instruments  that 
will  retain  their  position  when  placed  in  the  nostrils  are  preferred  by 
some  laryngologists  (Figs.  77  and  78).  No  special  directions  are  needed  for 
anterior  rhinoscopy,  excepting  that,  in  order  to  view  the  back  part 
of  the  nasal  cavities  from  the  front,  a  condenser,  and  a  reflector  as  de- 
scribed with  the  laryngoscope,  are  very  desirable,  and  it  is  absolutely 

(0> 


Fig.  77. — Jarvis1  Small  Nasal  Speculum  Q£  size). 


Fig.  78.— Sajous1  Self-retaining  Nasal 
Speculum  (3-5  size). 


necessary  that  the  light  be  properly  focussed  according  to  the  principles 
laid  down  in  speaking  of  condensing  lenses.  No  obstacles  will  be  found 
to  the  examination,  excepting  in  unruly  children,  unless  there  be  some 
deformity  or  swelling  of  the  turbinated  bodies.  The  latter  is  common, 
but  may  usually  be  quickly  reduced  by  a  small  amount  of  a  spray  of 
cocaine.  The  nares  are  usually  about  one-eighth  of  an  inch  in  width  and 
from  an  inch  to  two  inches  in  height.  The  inferior  turbinated  body  is 
seen  occupying  about  two-thirds  of  the  outer  wall;  and  the  middle  tur- 
binated, much  smaller,  is  seen  at  the  upper  part  of  the  cavity  occupying 
about  one-quarter  of  the  outer  wall,  and  usually  approaching  to  within 
from  one-twelfth  to  one-sixteenth  of  an  inch  of  the  septum. 

The  superior  turbinated  body  cannot  be  seen.     The  whole  cavity  is 


302 


THE   THUn AT. 


covered  with  smooth  mucous  membrane,  normally  of  about  the  same 
color  as  that  covering  the  gums,  but  often,  under  less  perfect  illu- 
mination, 'appearing  slightly  congested.  The  normal  relations  of  the 
parts,  about  an  inch  back  of  the  nostrils,  are  shown  in  the  accompany- 
ing cut  from  the  photograph  of  a  frozen  section  prepared  for  me  by  C. 
H.  Stowell,  of  Washington,  D.  C.  The  soft  tissues  are  somewhat  shrunk- 
en, as  always  found  in  the  cadaver. 

In  about  fcwo-thirda  of  all  cases  there  is  some  disparity  in  size  in  the 
two  cavities,  due  to  deflection  or  to  outgrowths  from  the  bony  or  carti- 


Fig.  79.— Cross-section  of  Head,  looking  from  before  backward  (4-5  natural  size).  Show- 
ing: a,  a,  middle  turbinated  bodies:  b.  b,  inferior  turbinated  bodies:  c.  c.c.  ethmoid  cells:  d.  d,  antra 
of  Hifrhmore  ;  e,  e.  orbits  :  /.  septum  :  y,  hard  palate 

laginous  septum.  Usually  the  turbinated  bodies  of  one  side  are  some- 
what swollen,  so  that  it  is  exceptional  to  find  the  nasal  cavities  exactly 
alike. 


POSTERIOR    RHINOSCOPY. 

Posterior  rhinoscopy,  or  inspection  of  the  vault  of  the  pharynx  and 
posterior  nares,  is  practised  with  instruments  similar  to  those  used  in 
the  inspection  of  the  larynx,  and  in  much  the  same  manner,  excepting 
that  a  smaller  mirror  is  necessary,  and  its  reflecting  surface  is  turned 
upward  instead  of  downward. 

A  mirror  from  half  to  five-eighths  of  an  inch  in  diameter  is  usually 
employed,  and  it  is  generally  best  to  have  a  flexible  stem,  which  may  be 
readily  bent  to  conform  to  the  floor  of  the  mouth  (Fig.  81). 

The  mirror  may  be  set  at  right  angles  to  the  stem,  or  at  the  same  angle 
as  the  laryngeal  mirrors,  or  at  an  angle  between  these  two;  but  this  is  a 
matter  of  little  importance,  as  the  obliquity  of  the  mirror  may  be  easily 
changed  by  raising  or  lowering  the  handle.     Special  throat  mirrors  have 


POSTERIOR  RHINOSCOPY. 


303 


been  constructed  for  rhinoscopy  (Fig.  80),  but  they  are  not  superior 
to  those  already  described.  A  tongue  depressor  will  commonly  be 
needed  in  rhinoscopy,  and  various  forms  of  blunt  hooks  and  other 
instruments  may  be  used  for  holding  the  uvula;  these  latter  are  rarely 
employed  and  are  seldom  if  ever  of  use  except  during  operations. 

In  rhinoscopy,  the  patient  should  sit  erect,  and  the  head  must  not  be 
thrown  backward,  but  may  be  slightly  inclined  forward.  The  physician 
should  take  a  position  as  for  laryngoscopy,  or  on  a  slightly  higher  level, 
and  the  light  should  be  placed  as  for  inspection  of  the  larynx,  except 


Fig.  80.— Fraenkel's  Rhixoscope.    The  angle  of  the  mirror  (a)  can  be  changed  at  will  by  moving 

the  sliding  rod  at  b 

that  it  should  be  on  a  level  with  the  patient's  mouth  instead  of  his  eyes. 
The  patient's  tongue  should  not  be  protruded,  but  must  be  left  in  the 
floor  of  the  mouth,  where  it  will  generally  need  to  be  held  by  a  tongue 
depressor,  though  some  patients  can  control  it  better  without  an  instru- 
ment. 

The  rhinoscope  in  general  use  is  a  number  one  or  number  two 
laryngeal  mirror,  the  stem  of  which  is  bent  to  conform  it  to  the  floor  of 
the  mouth  (Fig.  81).  It  is  to  be  warmed  and  introduced  with  the  same 
care  as  in  laryngoscopy,  with  the  reflecting  surface  upward.  It  should 
be  carried  back  to  the  posterior  pharyngeal  wall,  though  it  is  better 
to  avoid  touching  it.  The  surface  of  the  mirror  will  then  be  at  an 
angle  of  about  thirty  degrees  to  a  horizontal  plane.  The  stem  may  be 
rested  on  the  dorsum  of  the  tongue,  but  care  must  be  taken  not  to  touch 
the  base  of  this  organ.  The  handle  should  be  depressed  nearly  to  the 
lower  incisor  teeth.  A  common  cause  of  failure  in  this  examination  is 
holding  the  mirror  handle  too  high. 

The  mirror  should  be  introduced  first  on  one  side  of  the  uvula  and 


3<  »4 


77/F  THROAT. 


then  on  the  other,  to  give  a  view  of  different  parts.     In  some  cases  a 
larger  mirror  ma}'  be  used  if  it  is  held  completely  below  the  uvula. 

When  the  mirror  is  in  position,  if  only  the  posterior  wall  of  the 
pharynx  is  seen,  in  order  to  expose  the  posterior  Dares,  the  handle  must 
be  still  farther  depressed,  or  the  mirror  must  be  withdrawn  and  bent 
more  nearly  to  a  right  angle  with  the  stem.  If  at  first  only  the  uvula 
and  posterior  surface  of  the  palate  are  exposed,  the  handle  must  be  ele- 
vated to  obtain  a  view  of  the  posterior  nares  or  vault  of  the  pharynx. 


Fro.  Si.—  Position  for  Rhinoscopy,  showing  also  Curve  in  Stem  of  Mirror.    (Slightlj*  altered 

from  Browne.) 

The  mirror  may  be  rotated  slightly  to  obtain  an  image  of  the  lateral 
walls  of  the  pharynx  or  of  the  orifices  of  the  Eustachian  tubes. 


OBSTACLES   TO    POSTERIOR    RHINOSCOPY. 

Some  of  the  obstacles  to  rhinoscopy  are  the  same  as  those  to  laryn- 
goscopy, and  demand  similar  treatment.  Thus,  the  uvula  may  be  elon- 
gated and  the  fauces  may  lie  irritable. 

The  principal  difficulties  met  in  the  examination  of  the  posterior 
nares  are:  irritability  of  the  tongue  causing  the  patient  to  retch  when- 
ever an  attempt  is  made  to  depress  it  with  the  spatula;  an  elongated  or 
sensitive  uvula;  irritability  of  the  fauces;  too  close  approximation  of 
the  uvula  and  palate  to  the  posterior  pharyngeal  wall. 

Irritability  of  the  tongue  will  sometimes  prevent  the  use  of  a 
tongue  depressor,  but  it  may  generally  be  employed  if  the  physician  is 
careful  not  to  allow  it  to  slip  too  far  back  on  the  base  of  the  organ.  In 
many  cases  it  is  not  necessary  to  depress  the  tongue  with  any  instru- 
ment, if  patients  are  instructed  to  allow  it  to  remain  passive  in  the  floor 


OBSTACLES  TO  POSTERIOR  RHINOSCOPY.  305 

of  the  mouth.  A  hand  mirror,  in  which  the  patient  can  see  his  tongue, 
will  sometimes  aid  him  materially  in  controlling  it.  In  other  cases  the 
tongue  may  be  held  as  in  laryngoscopy. 

Some  one  of  these  methods  will  nearly  always  overcome  this  diffi- 
culty; but  if  they  should  all  fail,  the  patient  must  practise  at  home  be- 
fore a  mirror  until  a  spatula  can  be  tolerated,  or  until  the  tongue  can  be 
held  without  one. 

Instruments  have  been  constructed  which  combine  a  tongue  depressor 
and  the  throat  mirror;  but  they  are  not  necessary,  for,  whenever  the 
physician  desires  to  use  both  hands,  the  care  of  the  spatula  may  be  in- 
trusted to  the  patient.  Instruments  of  this  kind  are  objectionable,  as 
the  depressor  necessarily  greatly  restricts  the  movements  of  the  mirror. 

An  elongated  uvula,  so  relaxed  as  to  become  an  obstacle  to  the 
use  of  the  rhinoscopic  mirror,  may  be  contracted  by  astringents.  If 
the  uvula  is  too  long  to  be  managed  in  this  manner,  it  should  be  excised. 

Various  instruments  have  been  devised  for  raising  the  uvula  and 
drawing  it  forward,  but  they  are  of  very  little  service,  as  they  usually 
cause  so  much  irritation  that  they  cannot  be  borne. 

Irritability  of  the  fauces  can  be  overcome  in  many  instances 
by  allowing  the  patient  to  suck  bits  of  ice  for  ten  or  fifteen  minutes.  In 
other  cases  there  must  be  prolonged  practice  by  the  patient  at  home  in 
holding  the  tongue,  and  in  touching  the  palate  and  pharyngeal  wall 
with  a  spoon-handle. 

In  obstinate  cases  a  solution  of  cocaine  may  be  used  as  in  laryngos- 
copy. 

Closure  of  the  post-palatine  space,  by  contraction  of  the  pala- 
tine muscles,  often  occurs  the  moment  a  patient  opens  his  mouth,  and  it 
sometimes  continues  in  spite  of  our  best  directed  efforts  to  overcome  it. 
This  is  the  most  common  difficulty  with  which  we  have  to  contend  in 
illuminating  the  vault  of  the  pharynx  and  the  posterior  nares. 

Sometimes  this  difficulty  may  be  overcome  by  cautioning  the  patient 
to  allow  the  fauces  to  remain  passive  when  the  mouth  is  opened,  or  by 
directing  him  to  simply  open  the  mouth  wide  without  attempting  to 
show  the  throat.  Then,  by  introducing  the  mirror  carefully  so  as  not  to 
touch  any  part  of  the  fauces,  and  removing  and  reintroducing  it  several 
times  if  necessary  without  attempting  to  obtain  a  view  behind  the  palate, 
the  patient's  confidence  may  be  secured  and  the  examination  completed. 

If  the  patient  can  be  taught  to  breathe  quietly  through  the  nose 
during  the  examination,  the  palate  will  hang  loosely  so  as  to  cause  no 
trouble. 

Sometimes  a  view  may  be  secured  by  directing  the  patient  to  sound 
n  or  ng.  Frequently  a  glimpse  may  be  had  if  the  patient  will  attempt 
to  expire  through  the  nose. 

Various  palate  or  uvula  hooks  have  been  constructed  for  the  purpose 
of  overcoming  the  difficulty;  but,  as  has  been  well  stated,  the  time  spent 
20 


306 


THE  THROAT. 


in  teaching  the  patient  to  tolerate  them  is  usually  more  than  is  neces- 
sary to  educate  the  throat  to  maintain  a  position  which  will  require  no 
instrument.     Time,  patience,  and   frequent  practice  by  the  patient  at 


Fig.  82.— Rubber  Palate  Retractor  tJ-3Mz»-i 

home  must  be  the  main  dependence  for  successful  examination  in  these 
cases. 

When  operations  are  to  be  performed,  the  palate  may  be  drawn  for- 


Fig.  83.— Porchbr's  Self-retaining  Uvula  and  Palate  Retractor  (J^size.) 

ward  by  the  palate  retractor  (Fig.  S2),  or  by  tapes  passed  through 
the  nares  by  means  of  a  Bellocq's  canula  or  a  catheter,  and  brought  out  of 
the  mouth  and  tied.     Soft  rubber  catheters  passed  through  the  nares, 


Fig.  84.— Palate  Retractor  CJ^  size). 


brought  out  at  the  mouth,  and  tied  over  the  lip  are  very  convenient  for 
this  purpose  ;  or  the  palate  may  be  held  by  means  of  a  broad,  strong 
palate  retractor.     The  palate  retractor  ordinarily  sold  (Fig.  84)  is  only 


Fig.  85.— Rhinoscope  with  Uvula  Holder 


two-eighths  or  three-eighths  of  an  inch  in  width,  and  is  therefore  too 
small  for  this  purpose.  Combinations  of  mirrors  and  uvula  holders  have 
been  constructed,  but  they  do  not  give  general  satisfaction. 


VAULT  OF  THE  PHARYNX. 


307 


VAULT   OF  THE  PHARYNX  AND  POSTERIOR  NASAL  CAVITIES. 

On  account  of  the  small  size  of  the  mirror  which  we  are  generally 
obliged  to  use,  and  the  limited  space  through  which  the  rays  of  light 
can  be  reflected,  it  is  impossible  to  obtain  a  complete  image  of  the  posterior 
region  with  the  mirror  in  any  single  position,  but  by  slowly  turning  it 
from  side  to  side,  elevating  or  depressing  the  handle,  and  introducing 
the  mirror  first  on  one  side  of  the  uvula  and  then  the  other,  part  after 
part  can  be  brought  into  view. 

The  natural  condition  of  these  parts  should  be  thoroughly  studied 
from  diagrams  or  models,  before  an  attempt  is  made  to  inspect  them  in 
the  living  subject,  and  the  student  should  make  himself  perfectly  famil- 
iar with  the  description  of  different  parts.  When  the  mirror  is  first 
carried  into  the  throat,  we  usually  see  in  it  the  image  of  the  upper  sur- 


Fig.  86.— Rhinoscopic  Image.  1,  Vomer  or  septum  ;  2, 2,  free  space  of  nasal  passages  ;  3, 3,  supe- 
rior meatus  :  4, 4,  middle  meatus ;  5, 5,  superior  turbinated  body ;  6, 6,  middle  turbinated  body  ;  7, 7,  in- 
ferior turbinated  body  ;  8, 8,  pharyngeal  orifice  of  Eustachian  tube ;  9, 9,  upper  portion  of  fossa  of 
Rosenmueller  ;  11, 11,  glandular  tissue  at  the  anterior  portion  of  the  vault  of  the  pharynx  ;  12,  pos- 
terior surface  of  velum  palati  (Cohen). 

face  of  the  palate,  or  of  the  posterior  surface  of  the  uvula,  or  of  the  pos- 
terior wall  of  the  pharynx.  If  either  of  the  first  two  is  brought  into 
view,  we  then  elevate  the  handle  of  the  mirror,  or  if  the  last  is  seen  we 
depress  it,  and  thus  bring  into  the  field  of  vision  the  parts  just  above  the 
soft  palate.  We  then  search  for  the  septum  narium,  which  is  to  be 
taken  as  a  starting  point  for  further  inspection. 

Having  found  the  septum,  we  trace  it  throughout  its  entire  vertical 
length  from  the  narrow  lower  extremity,  where  it  joins  the  palate,  to  its 
upper  broad  base  which  arches  outward  on  either  side  at  the  top  of  the 
posterior  nares.  On  either  side  of  the  septum  the  irregular  outer  border 
of  the  posterior  opening  of  the  nasal  cavity  should  be  traced  from  above 
downward  past  the  projecting  turbinated  bodies  to  the  orifice  of  the 
Eustachian  tube,  and  finally  to  the  palate  and  lateral  walls  of  the 
pharynx.  The  middle  turbinated  body  is  the  most  prominent  object  at 
the  outer  part  of  the  nasal  opening ;  but  it  seems  overlapped  at  its 
lower  part  by  the  inferior  turbinated  body. 

External  to  the  middle  turbinated  body,  and  just  above  that  portion 


308  THE  THROAT. 

of  the  inferior  turbinated  body  which  seems  to  overlap  it,  is  a  dark 
space  known  as  the  middle  meatus;  and  slightly  external  to  the  latter 
is  the  orifice  of  the  Eustachian  tube. 

Some  physicians,  instead  of  following  this  course  in  their  inspection, 
prefer  to  start  from  the  Eustachian  tube,  but  this  is  merely  a  matter  of 
habit. 

The  septum  narium  divides  the  rhinoscopic  view  into  halves.  It 
forms  a  narrow,  shining  column  below,  near  the  palate,  which  gradually 
increases  in  breadth  toward  its  upper  part.  At  the  lower  part  it  appears 
of  a  pinkish,  yellowish,  or  whitish  color,  according  to  the  brilliancy  of 
the  illumination ;  but  toward  the  upper  part  or  base  the  color  deepens 
to  a  red  like  that  of  the  surrounding  mucous  membrane. 

The  color  of  the  parts,  as  here  described,  is  that  observed  by  means  of  arti- 
ficial light.     Natural  light  gives  a  paler  hue. 

The  sides  of  the  septum,  a  considerable  portion  of  which  may  be 
seen,  are  usually  of  a  drab  or  ashy- red  color,  slightly  darker  in  hue  than 
the  posterior  edge,  probably  on  account  of  being  less  perfectly  lighted. 
The  septum  seldom  occupies  exactly  the  centre  of  the  posterior  nares, 
but  inclines  slightly  to  oue  side. 

The  middle  turbinated  bodies  are  easily  found,  as  they  are  the 
most  prominent  objects  in  view  on  the  external  wall  of  the  nasal  cavity, 
of  which  they  seem  to  constitute  the  greater  part.  They  are  covered 
with  a  thin  mucous  membrane  of  a  pinkish  or  yellowish  white  color. 
The  middle  turbinated  body  sometimes  resembles  a  mucous  polypus,  for 
which  it  may  be  mistaken  by  the  student. 

The  inferior  turbinated  bodies  lie  just  below  the  preceding. 
They  are  considerably  smaller  than  the  middle  turbinated  bodies,  and  do 
not  approach  so  near  the  septum.  They  are  of  a  darker  color,  probably 
from  deficient  illumination.  Not  infrequently  they  have  the  appearance 
of  solid  tumors. 

The  Eustachian  orifice  on  either  side  is  found  a  little  external 
and  posterior  to  the  inferior  turbinated  body,  usually  on  a  level  with  the 
middle  meatus,  but  sometimes  slightly  above  or  below  it. 

Thi  opening  has  an  irregularly  triangular  or  crescentic  shape.  It 
usually  measures  about  a  quarter  of  an  inch  in  its  longest  diameter,  but 
it  is  sometimes  large  enough  to  admit  the  tip  of  the  little  finger.  The 
opening  looks  downward,  inward,  and  slightly  forward;  it  is  bounded  by 
two  more  or  less  prominent  projections  called  the  anterior  and  posterior 
walls  or  lips  of  the  orifice,  which  are  covered  with  a  light  red  or  yellow- 
ish mucous  membrane.  The  former  consists  mainly  of  the  fibres  of  the 
levator  palati  muscle,  and  the  latter  of  the  cartilaginous  extremity  of  the 
Eustachian  tube.  From  the  posterior  or  lower  lip  a  prominent  ridge, 
formed  by  the  levator  palati  muscle,  runs  downward  and  inward  to  the 
soft  palate.     From  the  anterior  or  upper  lip  a  dark  groove  runs  upward 


VAULT  OF  THE  PHARYNA'. 


309 


and  outward  toward  the  vault  and  the  posterior  walls  of  the  pharynx. 
This  groove  is  known  as  the  fossa  of  Kosenmueller  or  the  recessus 

PHARYNGEI. 

The  choanje  or  posterior  openings  of  the  nares  are  seen  in  front  of 
the  retro-nasal  space.  They  are  of  oval  form  and  usually  about  one-half 
an  inch  wide  by  three-quarters  of  an  inch  in  height.  Harrison  Allen 
(Transactions  of  the  American  Laryngological  Association,  1888)  has 
shown  that  they  are  not  infrequently  of  unequal  size,  without  deviation 
of  the  septum,  the  left  being  usually  the  smaller. 

The  superior  turbinated  bodies  are  located  at  the  upper  part  of 
the  nasal  fossae  and  cannot  be  distinctly  seen.     They  have  the  appear- 


Fig.  87.— Adenoid  Tissue  at  Vault  op  Phar- 
ynx. Posterior  wall  of  upper  part  of  pharynx 
(Luschka).  1,  1,  Pterygoid  process  ;  2,  section 
of  vomer  ;  3,  3,  posterior  portion  of  the  vault  of 
the  nasal  fossae  ;  4,  4,  pharyngeal  orifice  of  the 
Eustachian  tube  ;  5,  orifice  of  the  bursa  pharyn- 
gea  ;  6.  6,  recessus  pharyngeus  (fossa  of  Rosen- 
mueller) ;  7,  median  folds  formed  by  the  adenoid 
substance  of  the  nasal  portion  of  the  pharynx. 


Fig.  88.—  Pharyngeal  Bursa.  Anteroposte- 
rior section  (Luschka).  1,  Section  of  basilar 
process  of  the  occipital  bone  ;  2,  body  of  sphe- 
noid ;  3,  pituitary  gland  ;  4,  adenoid  substance 
of  the  vault  of  the  pharynx,  behind  which  is  seen 
5,  the  pharyngeal  bursa. 


ance  of  narrow  triangular  projections,  the  apices  of  which  point  down- 
ward and  inward.  Their  color  is  dark  red,  like  that  of  the  base  of  the 
septum. 

The  superior,  middle,  and  inferior  meatus  are  the  spaces 
found  between  the  turbinated  bodies  and  the  external  wall  of  the  nasal 
cavity.  The  superior  meatus,  which  is  the  largest,  appears  as  a  large 
shadow  at  the  upper  part  of  the  fossa,  just  below  the  superior  turbinated 
body.  The  middle  meatus  is  seen  as  a  dark  opening  near  the  middle 
part  of  the  fossa,  external  to  the  middle  turbinated  body.  The  inferior 
meatus,  if  seen  at  all,  generally  appears  simply  as  a  dark  line. 

The' vault  of  the  pharynx  is  known  also  as  the  fornix  pharyngis, 


old  THE  THROAT. 

and  is  sometimes  spoken  of  as  the  tonsilla  pharyngea.  It  is  that  por- 
tion of  the  pharyngeal  wall  which  begins  at  the  posterior  nasal  orifices 
and  extends  backward  along  the  basilar  process  of  the  occipital  bone, 
and  then  downward  to  be  lost  in  the  posterior  pharyngeal  wall. 

In  the  perspective  view,  which  we  obtain  of  this  part  by  rhinoscopy, 
it  appears  shorter  than  natural.  The  mucous  membrane  is  of  a  light 
red  color,  studded  with  minute  whitish  follicles,  and  broken  on  its  sur- 
faces into  irregular,  more  or  less  longitudinal  fissures  and  ridges,  which 
give  it  much  the  appearance  of  the  surface  of  the  faucial  tonsil.  This 
appearance  of  the  surface  is  caused  by  glandular  tissue  which  has  re- 
ceived the  name  of  tonsilla  pharyngea.  Near  the  middle,  at  the 
lower  part  of  this  glandular  tissue,  is  an  opening  about  the  size  of  a  pin's 
head,  which  leads  up  into  a  small  cul  de  sac,  known  as  the  bursa 
pharyngea.  The  posterior  surface  of  the  uvula,  palate,  and  pillars  of 
the  fauces  may  be  seen  below  the  nasal  fossae.  The  palate  appears  in  the 
rhinoscopic  image  as  a  fleshy  ledge  running  at  right  angles  with  the 
septum. 


CHAPTER  XVIII.  . 

DISEASES   OF   THE   FAUCES. 
ACUTE   SORE   THROAT. 

Synonyms. — Erythematous  or  catarrhal  sore  throat,  cynanche  pharyn- 
geal and  others. 

An  acute  inflammation  may  affect  the  mucous  membrane  of  the 
palate,  pharynx,  or  tonsils,  or  all  combined.  Acute  sore  throat  is  found 
among  people  of  all  classes  and  occurs  at  all  ages,  but  most  frequently  in 
young  adults  or  children.  It  is  said  to  be  more  common  in  those  who 
have  suffered  from  syphilis  or  who  have  been  mercurialized,  and  among 
those  who  follow  sedentary  occupations.  It  is  most  often  observed  dur- 
ing the  changeable  weather  of  spring  or  autumn. 

Anatomical  axd  Pathological  Chaeactekistics. — There  is  at 
first  simple  active  hyperemia  of  the  mucous  membrane  of  the  palate, 
pharynx,  or  tonsil,  either  circumscribed  or  diffused.  Later,  more  or  less 
swelling  occurs,  generally  noticed  at  first  in  the  uvula.  In  some  cases 
the  mucous  membrane  lies  in  thick  folds,  and  occasionally  the  uvula  and 
posterior  pillars  of  the  fauces  are  cedematous.  The  superficial  blood- 
vessels are  frequently  distended,  and  soon  the  muscular  and  glandular 
tissues  become  involved,  and  the  secretions,  primarily  arrested,  are  again 
established,  but  changed  both  in  quantity  and  quality.  In  some  cases  the 
inflammation  may  terminate  in  suppuration. 

Etiology. — Acute  sore  throat  is  commonly  caused  by  exposure  to 
colds  or  draughts,  especially  in  subjects  who  are  living  under  the  de- 
pressing influence  of  poor  food,  bad  air,  or  scanty  clothing;  it  also  arises 
from  sitting  in  warm  rooms  with  heavy  wraps,  or  working  in  a  superheat- 
ed atmosphere,  and  then  going  out  into  the  cold.  Among  the  occasional 
causes  are  extension  of  inflammation  from  surrounding  tissues,  the  in- 
halation of  poisonous  gases,  the  abuse  of  tobacco,  the  inhalation  of  steam, 
the  taking  into  the  mouth  of  irritant  poisons  or  of  hot  fluids,  the  im- 
paction in  the  fauces  of  foreign  bodies,  and  possibly  the  excessive  use  of 
spices.  Over-use  of  the  voice  in  poorly  ventilated  rooms  or  in  the  open 
air,  especially  at  night,  may  be  an  exciting  cause.  Among  the  jjredis- 
posing  factors  are  the  syphilitic,  rheumatic,  and  scrofulous  diatheses. 

Symptomatology. — In  mild  cases  the  patient  at  first  suffers  simply 
from  malaise,  but  soon  experiences  more  or  less  headache  and  pain 
in  the  neck,  back,  and  limbs.  In  severe  cases  the  pain  and  constitu- 
tional symptoms  are  marked.  Early  there  is  irritation  or  a  sense  of 
itching  in  the  throat,  with  pricking  pain.  A  few  hours  later  pain  be- 
comes severe,  especially  as  the  patient  attempts  to  swallow. 


312  DISEASES   OF  THE  FAUCES. 

When  the  inflammation  is  in  the  upper  part  of  the  pharynx,  the  pain 

often  radiates  toward  the  ears,  and  there  is  more  or  less  deafness,  due  to 
extension  along  the  Eustachian  tubes.  If  the  inflammation  is  at  the 
inferior  portion  of  the  pharynx,  the  patient  suffers  from  movements  of 
the  larynx,  which  is  also  sensitive  on  pressure.  In  severe  cases  the  skin 
is  hot,  the  temperature  ranging  at  about  103°  F.  Indeed,  the  constitu- 
tional symptoms  are  out  of  all  proportion  to  the  amount  of  inflammation 
in  the  throat.  The  pulse  ranges  from  '.tn  to  120  or  even  140,  according 
to  the  extent  of  inflammation  and  the  susceptibilities  of  the  individual, 
all  the  symptoms  being  more  marked  in  children  than  in  adults.  The 
voice  often  has  a  nasal  twang,  due  to  swelling  of  the  palate  and  uvula 
and  to  pressure  on  the  pharyngeal  and  palatine  muscles  by  the  inflamma- 
tory deposit.  There  is  no  hoarseness.  Cough  does  not  usually  disturb  the 
patient,  unless  the  uvula  becomes  much  elongated.  There  is,  however, 
an  annoying  tendency  to  hawk  and  clear  the  throat  of  the  secretions, 
throughout  a  considerable  portion  of  the  disease.  At  first  there  is  but 
little  expectoration ;  later  the  secretions  are  more  abundant,  thick  and 
tenacious,  and  hard  to  expectorate;  finally  they  become  muco-purulent. 
The  tongue  is  nearly  always  furred,  the  breath  is  feverish  and  offensive, 
the  bowels  are  constipated,  and  the  urine  is  high  colored.  Upon  exam- 
ination of  the  throat,  the  mucous  membrane  will  be  found  of  a  bright 
red  color,  which  may  be  limited  to  patches  or  diffused  over  the  whole 
surface.  The  superficial  blood-vessels  are  often,  though  not  always  en- 
larged; the  uvula  is  usually  congested  and  swollen,  and  occasionally  the 
same  condition  extends  to  the  posterior  pillars  of  the  fauces.  The  soft 
palate  may  also  be  considerably  swollen,  its  edges  having  an  cedematous 
appearance.  Whenever  oedema  occurs,  the  mucous  membrane  is  some- 
what translucent  and  of  a  lighter  red  color.  The  inflammation  may 
extend  over  the  palate,  tonsils,  and  pharyngeal  wall,  and  sometimes  the 
swelling  of  the  mucous  membranes  causes  large  longitudinal  welts  back 
of  the  posterior  pillars.  Occasionally,  in  severe  cases,  the  parts  are  al- 
most livid.     The  cervical  glands  are  very  apt  to  be  slightly  enlarged. 

Diagnosis. — Acute  sore  throat  is  to  be  distinguished  from  scarlatina, 
acute  tonsillitis,  and  rheumatic  sore  throat.  The  constitutional  symp- 
toms in  scarlatina  are  more  marked  than  in  acute  sore  throat,  and  usu- 
ally after  a  few  hours  a  characteristic  rash  appears  upon  the  skin. 
There  is  at  first  congestion  in  acute  tonsillitis  and  pain  similar  to  that  in 
acute  sore  throat,  but  shortly  the  glands  swell  sufficiently  to  distinguish 
it  from  the  disease  under  consideration.  Again  in  acute  tonsillitis  the 
inflammation  is  apt  to  be  confined  mostly  to  one  side  for  the  first  two 
or  three  days.  The  pain  is  greater  in  acute  rheumatic  sore  throat 
and  the  congestion  usually,  though  not  invariably,  less  than  in  simple 
acute  sore  throat,  and  there  is  nearly  always  a  rheumatic  diathesis 
or  a  history  of  previous  attacks,  which  aid  in  establishing  the  diag- 
nosis. 


ACUTE  SORE  THROAT.  313 

Pkogxosis. — Acute  sore  throat  runs  its  course  in  from  seven  to  ten 
days,  and  is  not  dangerous  to  life:  but  often  there  remains  a  tendency 
to  frequent  recurrence  of  the  attacks.  In  very  rare  cases  it  has  proved 
fatal  by  extension  to  the  larynx. 

Teeatmext. — Patients  subject  to  acute  sore  throat  should  be  espe- 
cially cautious  about  exposure;  they  should  so  clothe  themselves  as  not 
to  feel  sudden  changes  of  temj)erature;  they  should  not  sit  in  damp  or 
overheated  rooms,  and,  in  a  word,  should  avoid  all  the  known  causes  of 
the  affection.  The  cold  sponge  bath  is  of  undoubted  efficacy  in  prevent- 
ing the  taking  of  colds.  I  direct  patients  to  sponge  the  trunk  once  a  day 
with  cold  water  as  it  comes  from  the  hydrant,  either  morning  or  evening 
as  best  suits  their  convenience  or  inclination.  For  the  rugged,  the  morn- 
ing sponge  bath  is,  as  a  rule,  better,  but  for  others  I  advise  sponging  at 
night  in  a  warm  room.  The  bath  should  be  taken  quickly,  and  the  skin 
rubbed  vigorously  with  a  coarse  towel  to  establish  reaction.  Full  doses 
of  quinine  will  sometimes  abort  an  attack  of  acute  sore  throat.  For  this 
purpose,  from  six  to  ten  grains  should  be  given  in  a  single  dose,  accord- 
ing to  the  peculiarities  of  the  individual.  Early  in  the  attack,  ice  sucked 
continuously  or  applied  about  the  neck  in  a  rubber  bag  will  frequently 
abort  the  inflammation.  If  the  disease  is  not  checked  by  these  means, 
I  advise  small  doses  of  ojfium,  aconite,  or  belladonna,  administered  as 
follows :  the  tincture  of  opium,  one  minim  every  ten  to  thirty  minutes 
at  first,  and  less  frequently  as  the  patient  experiences  relief  from  the 
throat  symptoms;  or  the  tincture  of  aconite,  one  minim  every  fifteen  to 
thirty  minutes  for  three  or  four  hours  until  perspiration  is  established, 
when  the  throat  symptoms  are  generally  relieved;  subsequently  once  in 
one  or  two  hours  according  to  the  fever;  tincture  of  belladonna  is  given 
in  similar  doses  with  benefit  in  certain  cases.  I  often  rely  upon  potas- 
sium bromide  alone,  or  with  small  doses  of  opium  when  the  latter  is 
well  borne.  The  bromide  is  given  in  doses  of  ten  or  fifteen  grains  every 
three  or  four  hours,  according  to  the  amount  of  pain.  As  the  disease  often 
occurs  in  persons  of  a  rheumatic  diathesis,  and  since  it  is  sometimes  im- 
possible to  determine  whether  or  not  the  rheumatic  diathesis  exists,  a 
good  practice  is  to  alternate  potassium  bromide  with  sodium  salicy- 
late in  doses  of  seven  and  one-half  grains  or  more  every  third  hour.  If 
the  disease  progresses,  inhalations,  from  a  steam  atomizer,  of  solutions  of 
the  aqueous  extract  of  opium,  or  of  belladonna  gr.  i.  to  ij.;  or  carbolic  acid 
gr.  ij.  in  four  drachms  each  of  glycerin  and  water,  will  often  be  found 
very  soothing.  If  there  be  constipation,  it  is  desirable  to  give  a  saline 
cathartic.  Some  physicians  favor  a  mercurial  purge  at  first,  especially 
in  patients  with  engorgement  of  the  portal  system.  It  should  be  given  in 
a  single  dose — for  example,  calomel  gr.  v.,  with  sodium  bicarbonate  gr. 
v. — and  followed  after  six  or  eight  hours  by  a  saline  laxative.  In  nearly 
all  affections  of  the  throat,  potassium  chlorate  is  commonly  administered; 
it  is  not  certain  that  it  has  verv  much  influence  on  these  diseases;  but 


314  DISEASES  OF  THE  FAUCES. 

used  as  a  hot  gargle  in  connection  with  potassium  nitrate,  I  find  it 
often  beneficial.  I  order  one  part  of  potassium  chlorate  to  two  parts 
of  the  nitrate  in  powder,  and  direct  the  patient  to  use  of  this  a  heaping 
teaspoonful  dissolved  in  half  a  teacup  of  water,  hot  as  can  be  borne, 
every  half-hour  or  hour  according  to  the  severity  of  the  symptoms. 
Sometimes  the  act  of  gargling  is  very  painful.  In  such  cases  the  patient 
should  simply  hold  the  solution  in  the  throat  as  long  as  possible.  In 
the  latter  part  of  the  disease,  astringent  gargles  of  alum  or  tannic  acid 
are  usually  recommended,  but  they  are  very  unpleasant  to  most  patients 
and  do  not  appear  to  materially  shorten  the  period  of  resolution. 
Astringent  troches  may  be  easily  taken,  and  will  be  found  beneficial  at 
this  time.  For  this  purpose  troches  of  krameria,  each  containing  three 
grains  of  the  extract,  may  be  given  every  two  or  three  hours.  Guaiacum 
is  recommended  in  cases  of  rheumatic  origin,  given  during  the  first  two 
or  three  days  every  two  hours,  in  troches  each  containing  two  or  three 
grains  of  the  resin ;  or  in  the  ammoniated  tincture,  best  administered  in 
doses  of  one  drachm  every  three  or  four  hours.  I  have  seen  a  few  cases 
benefited  by  it,  but  ordinarily  it  has  been  disappointing.  Cocaine  has 
been  recommended  for  the  pain,  but  the  practice  should  be  condemned, 
as  an  amount  sufficient  to  give  relief  cannot  be  applied  without  produc- 
ing marked  constitutional  effects,  and  the  relief  will  not  continue  more 
than  fifteen  or  twenty  minutes;*  if  at  the  end  of  this  time  the  applica- 
tion is  repeated,  it  is  sure  to  do  harm.  Demulcents,  as,  for  example, 
flaxseed  tea,  infusion  of  slippery  elm  bark,  or  rice  water,  are  useful  in 
allaying  inflammation  and  furnishing  some  nutrition.  The  patient  will 
be  obliged  for  a  few  days  to  take  light  diet  consisting  of  soups,  broths, 
beef  tea,  and  milk.  If  the  uvula  should  become  very  cedematous,  it 
should  be  scarified  or  punctured  to  allow  the  serum  to  escape,  but  it  must 
not  be  cut  off,  lest,  when  the  patient  recovers,  it  be  found  much  shorter 
than  normal.  If  the  patient  suffers  from  heat  and  burning  of  the  skin, 
sponging  the  surface  with  water,  or  alcohol  and  water,  will  be  found  very 
grateful. 

ERYSIPELATOUS  SORE   THROAT. 

Erysipelatous  sore  throat  is  a  rare  affection,  which,  when  occurring, 
is  usually  associated  with  facial  erysipelas.  Oornil  {Arch ires  Generates 
de  Medecine,  1S62)  makes  three  divisions  of  the  disease:  first,  erysipelas 
in  which  there  is  diffused  redness  varying  from  scarlet  to  deep  lividity  of 
the  mucous  membrane,  with  more  or  less  swelling  and  a  shining  appear- 
ance of  the  surface;  second,  erysipelas  with  phlyctenular  or  follicles 
ranging  in  size  from  a  pin's  head  to  a  centimetre  in  diameter,  similar  to 
those  sometimes  found  upon  the  skin  in  erysipelas,  which  contain  serum 
at  first,  but  soon  rupture,  the  surface  becoming  coated  with  a  thin, 
membranous   formation  ;    third,    erysipelas   which    eventuates   in   gan- 


ERYSIPELATOUS  SORE  THROAT.  315 

grene,  characterized  by  a  dark  pultaceous  appearance  of  the  mucous 
membrane  and  an  odor  peculiar  to  gangrenous  tissue. 

Etiology. — This  variety  of  sore  throat  is  produced  by  the  same  con- 
ditions that  cause  erysipelas  of  the  face  or  of  other  portions  of  the  skin, 
and  is  supposed  to  result  from  infection  by  a  specific  microorganism 
the  streptococcus  erysipelatosus.  The  affection  is  more  frequent  during 
epidemics  of  erysipelas. 

Symptomatology. — In  most  cases  the  patient  is  attacked  by  facial 
erysipelas,  which  continues  two  or  three  days  before  the  throat  becomes 
involved.  In  rare  instances,  the  inflammation  starts  in  the  fauces,  Pre- 
ceding its  development,  the  patient  usually  suffers  from  malaise  for  three 
or  four  days.  Constitutional  symptoms  are  more  marked  in  erysipelas 
of  the  throat  than  in  simple  facial  erysipelas. 

Fever  ranging  from  101°  to  104°  F.  sometimes  occurs  before  conges- 
tion is  observed  either  of  the  throat  or  skin.  Often  there  is  nausea,  and 
pain  at  the  epigastrium.  The  patient  complains  of  dryness  or  a  sting- 
ing pain  in  the  throat  with  stiffness  of  the  jaws,  so  that  there  is  difficulty 
in  opening  the  mouth.  Usually  there  is  swelling  of  the  submaxillary 
and  cervical  glands.  Deglutition  becomes  exceedingly  painful,  and  is 
sometimes  difficult  on  account  of  paresis  of  the  muscles.  When  the 
muscles  of  the  palate  alone  are  involved,  food  will  be  partially  regurgi- 
tated through  the  nose. 

Diagnosis. — Upon  examination  of  the  throat,  in  the  erythematous 
variety,  the  mucous  membrane  covering  the  palate,  tonsils,  and  pharynx 
has  a  shining  surface  and  bright  red  color,  or  in  severe  cases  displays  a 
deep  livid  hue.  In  cases  marked  by  phlyctaenulae  or  gangrene,  the  appear- 
ance of  the  eruption  or  the  color  and  odor  of  the  dead  tissue  would  sug- 
gest the  character  of  the  affection;  in  those  where  the  throat  is  attacked 
first,  the  speedy  occurrence  of  an  eruption  upon  the  skin  will  clear  up 
the  diagnosis.  Usually  the  skin  is  first  attacked,  so  that  when  the 
throat  symptoms  appear,  the  nature  of  the  disease  is  at  once  suspected. 

Prognosis. — The  affection  may  run  its  course  to  either  recovery  or 
death  in  two  or  three  days,  but  in  the  majority  of  cases  it  lasts  eight  or 
ten  days.  One-half  of  the  patients  die,  and  in  those  who  recover  resolu- 
tion is  slow.  In  fatal  cases,  the  disease  may  extend  to  the  larynx,  caus- 
ing suffocation,  or  the  patient  may  succumb  to  blood  poisoning  or  ex- 
haustion, with  or  without  the  formation  of  abscesses.  In  gangrenous 
cases,  death  is  almost  certain. 

Treatment. — In  a  disease  so  often  fatal,  the  treatment  cannot  be 
very  satisfactory,  but  anything  which  offers  hope  should  be  tried.  An 
application  of  a  sixty  grain  solution  of  silver  nitrate  very  early  in  the 
attack  has  seemed  to  cut  it  short  in  some  cases.  Constant  sucking  of 
ice  has  been  found  beneficial  in  moderating  the  severity  of  the  inflam- 
mation, and  is  to  be  recommended,  at  least  during  the  first  few  hours  of 
the  disease.     As  the  patient  suffers  much  from  pain  and  restlessness, 


31 G  DISEASES  OF  THE  FAUCES. 

opiates  should  be  administered  in  sufficient  quantity  to  give  relief,  unless 
there  is  an  idiosyncrasy  to  the  contrary.  Because  of  the  tendency  of 
the  disease  to  death  by  exhaustion,  stimulants  and  tonics  are  indicated. 
Quinine  should  be  given  in  doses  of  two  or  three  grains,  averaging  about 
a  grain  for  each  hour  of  the  day  and  night.  The  tincture  of  chloride  of 
iron  has  seemed  the  best  internal  remedy  for  erysipelas  of  the  skin,  and 
is  therefore  recommended  in  erysipelatous  inflammation  of  the  throat. 
It  should  be  given  in  doses  of  ten  or  fifteen  minims  about  every  two 
hours,  diluted  sufficiently  to  enable  the  patient  to  take  it  without  pain; 
glycerin  and  syrup  of  ginger  best  cover  its  taste.  In  cases  where  ap- 
plications of  cold  do  not  check  the  inflammation,  Mackenzie  recommends 
warm  fomentations  and  inhalations  of  steam,  or  steam  impregnated  with 
toothing  remedies,  anodynes,  or  carbolic  acid  and  glycerin.  Hot  ap- 
plications should  not  be  made,  however,  until  we  have  become  convinced 
that  the  inflammation  cannot  be  aborted.  Frequent  gargling  with  a 
one  per  cent  solution  of  carbolic  acid  is  sometimes  beneficial.  If  much 
oedema  of  the  throat  occurs,  scarification  should  be  practised  to  relieve 
the  tension  of  the  tissues;  and  if  the  disease  extends  to  the  larynx, 
as  it  frequently  does,  tracheotomy  must  be  performed.  Unfortunately, 
however,  the  operation  is  usually  futile'  in  this  affection.  In  gangrenous 
cases,  antiseptic  washes  of  carbolic  acid  gr.  vi.  ad  1  i.,  potassium  per- 
manganate gr.  v.  to  x.  ad  3  i.  or  listerine  3  ii-  ad  3  i.  should  be  frequently 
used,  and  we  should  urge  the  patient  to  take  freely  of  alcoholic  stimu- 
lants and  liquid  food. 

RHEUMATIC  SORE  THROAT. 
ACUTE    RHEUMATIC    SORE   THROAT. 

Rheumatic  sore  throat  may  be  considered  as  of  two  varieties,  the  acute 
and  the  chronic.  The  acute  affection  is  often  attended  by  marked  con- 
stitutional symptoms  and  severe  pain,  and  is  especially  frequent  in  pa- 
tients of  a  rheumatic  diathesis. 

Anatomical  axd  Pathological  Characteristics. — The  throat  is 
more  or  less  red  and  swollen,  but  usually  much  less  so  than  in  simple 
acute  sore  throat,  and  seldom  sufficiently  to  account  for  the  severe  pain. 

Etiology. — The  disease  is  produced  by  the  same  causes  which  set  up 
rheumatic  inflammation  in  other  parts. 

Symptomatology. — There  is  almost  always  a  rheumatic  diathesis, 
the  patient  being  subject  to  frequent  attacks  of  muscular  rheumatism, 
or  having  suffered  at  some  time  from  the  articular  affection. 

An  attack  comes  on  suddenly  and  is  announced  by  severe  pain  in 
the  throat,  which  is  soon  followed  by  constitutional  symptoms.  These 
usually  continue  for  a  couple  of  days,  and  then  almost  as  suddenly  dis- 
appear, the  pain  shifting  from  the  throat  to  the  muscles  of  the  neck, 


ACUTE  RHEUMATIC  SORE  THROAT.  317 

back,  or  extremities.  Occasionally  the  disease  passes  off  with  acute  artic- 
ular rheumatism.  The  pain  is  so  peculiar  that  patients  who  have  once 
had  the  disease  will  usually  recognize  it  immediately  from  the  character 
of  this  symptom.  It  is  very  severe  upon  attempts  at  swallowing  even 
saliva.  Sudden  shifting  of  the  pain  from  the  throat  to  the  muscles 
of  the  neck  or  back,  about  the  second  day,  is  one  of  the  notable  features 
of  the  disease.  The  temperature  is  raised  two  or  three  degrees  and  the 
pulse  is  correspondingly  quickened.  Upon  examining  the  fauces,  we 
find  more  or  less  redness  and  swelling,  which  may  be  uniform,  but  often 
consists  simply  of  red  stripes  running  longitudinally  behind  the  posterior 
pillars  of  the  fauces  upon  each  side,  while  other  portions  of  the  throat 
are  but  very  slightly  congested;  yet  the  patient  suffers  intensely. 

Diagnosis. — The  disease  is  not  likely  to  be  confounded  with  any 
other  excepting  simple  acute  sore  throat.  The  distinguishing  features 
are :  the  peculiar  pain,  the  history  of  former  attacks,  the  suddenness  with 
which  the  attack  comes  on,  and  the  shifting  of  the  pain  after  thirty-six 
or  forty  hours  to  some  other  portion  of  the  body.  There  is  generally 
much  less  of  redness  and  swelling  than  in  simple  sore  throat. 

Prognosis. — The  affection  usually  terminates  in  from  two  to  four 
days.  There  is  very  little  danger  so  far  as  life  is  concerned.  I  know 
of  only  one  reported  fatal  case;  in  that,  the  disease  extended  to  the 
larynx. 

Treatment. — Prophylaxis  is  of  first  importance  in  this  affection. 
Patients  subject  to  it  should  wear  either  silk  or  woollen  underclothing 
the  year  round,  and  should  be  careful  to  keep  the  feet  dry  and  warm, 
and  to  avoid  all  undue  exposure.  Early,  an  effort  should  be  made  to 
abort  the  attack  by  means  of  salicylates,  alkalies,  or  guaiacum.  Sodium 
salicylate  may  be  given  in  the  manner  recommended  for  acute  sore  throat, 
or  salicylic  acid  in  capsules  or  solution,  in  closes  of  five  or  ten  grains 
every  one  or  two  hours.  After  a  few  doses,  the  patient  usually  breaks 
out  in  a  profuse  perspiration,  and  the  pain  subsides.  When  this  occurs, 
the  dose  should  be  reduced  one-half,  and  continued  in  that  quantity  for 
five  or  six  doses,  when  it  should  be  further  decreased  or  substituted  by 
the  alkalies.  When  this  remedy  is  administered  in  capsules,  the  patient 
should  always  take  freely  of  water  with  each  dose,  to  avoid  irritation  of 
the  stomach.  Potassium  acetate  in  doses  of  twenty  to  thirty  grains,  or 
ammoniated  tincture  of  guaiacum  in  doses  of  one  drachm  may  be  given 
every  fourth  hour,  or  troches  of  guaiacum  may  be  taken  every  two  hours. 
On  account  of  the  severe  pain,  anodynes  may  be  required;  of  these, 
opiates  are  most  efficient,  but  the  peculiarities  of  many  patients  render 
this  drug  obnoxious,  and  therefore  potassium  bromide,  phenacetine  or 
antipyrine  or  similar  substances  are  often  preferable.  Applications  to 
the  throat  of  warm  fomentations  or  poultices  often  have  a  beneficial 
effect. 


318  DISEASES   OF  THE  FAUCES. 

CHRONIC   RHEUMATIC   SOUK   THEOAT. 

Synonym. — Chronic  rheumatic  laryngitis. 

Chronic  rheumatic  sore  throat  is  a  painful  affection  varying  much  in 
severity  from  time  to  time  and  attended  by  only  slight  physical  changes 
in  the  parts  involved.  Though  it  usually  affects  the  larynx,  and  there- 
fore has  been  described  as  rheumatic  laryngitis,  yet  in  many  cases  it  in- 
volves only  the  fauces,  the  hyoid  bone,  or  possibly  the  trachea,  without 
implicating  the  larynx;  therefore  the  term  chronic  rheumatic  sore 
throat  is  preferable.  It  is  comparatively  frequent,  and  has  probably  ex- 
isted from  time  immemorial. 

I  have  been  unable  to  find  any  description  of  it  prior  to  that  which  I  gave  at 
the  Ninth  International  Medical  Congress,  held  at  Washington,  D.  C,  in  1887. 

The  affection  occurs  mainly  in  the  spring  and  fall,  but  may  also  be 
observed  during  the  winter,  and  there  are  occasional  cases  in  which  it 
continues  through  the  summer  months.  Though  affecting  all  classes 
with  the  same  impartiality  as  rheumatism  of  other  parts,  it  is  more  fre- 
quent in  men  than  in  women,  and  all  the  cases  I  have  seen  have  been  in 
adults  from  twenty  to  .sixty  years  of  age. 

Anatomical  and  Pathological  Characteristics. — Xo  very 
marked  characteristics  appear,  although  there  is  usually  slight  conges- 
tion, circumscribed  in  character,  but  changeable. 

Etiology. — The  disease  is  due  to  the  same  causes  as  muscular  or 
articular  rheumatism. 

Symptomatology. — Chronic  rheumatic  sore  throat  comes  on  insidi- 
ously in  many  cases,  in  others  suddenly.  Commonly  the  patient  will 
have  been  complaining  for  months  when  he  applies  to  the  laryngologist 
for  relief.  Most  of  the  cases  I  have  seen  have  previously  consulted  sev- 
eral physicians  and  have  received  almost  as  many  different  diagnoses, 
but  all  have  feared  either  tuberculosis,  syphilis,  or  cancer,  most  of  them 
having  a  fixed  dread  of  the  latter  affection.  The  general  health  is  not 
impaired.  The  patient  complains  simply  of  a  localized  jDain,  commonly 
referred  to  the  cornu  of  the  hyoid  bone;  I  have  observed  it  most  fre- 
quently on  the  right  side.  Next  in  frequency,  pain  is  felt  in  the 
larynx,  as  a  rule  upon  one  side  only.  Occasionally,  however,  it  is  in 
the  trachea  or  tonsils,  and  sometimes  in  the  side  of  the  base  of  the 
tongue.  This  pain  is  increased  by  pressure  in  nearly  all  cases,  perhaps 
in  all,  and  it  may  be  increased  by  phonation  or  deglutition,  but  often  it 
completely  disappears  while  the  patient  is  eating.  In  any  case  it  is  lia- 
ble to  shift  its  position  from  time  to  time,  but  it  may  persist  for  weeks 
in  one  place.  Sometimes  the  person  will  complain  of  sensations  of 
fulness  or  swelling  or  of  dryness,  itching,  burning,  or  an  indescribable 
sensation  of  discomfort  instead  of  an  actual  pain.  Usually  the  voice  is 
not  affected,  yet  it  is  common  for  these  patients  to  complain  of  fatigue 
after  speaking  a  short  time.     There  is  no  fever,  and  no  quickening  of  the 


CHRONIC  RHEUMATIC  SORE  THROAT.  319 

pulse  except  from  alarm.  Usually  there  is  uo  cough,  but  in  some  cases, 
especially  where  the  larynx  is  involved,  an  annoying,  hacking  cough  is 
a  prominent  symptom.  The  digestive  organs  may  act  perfectly,  but 
ordinarily  the  tongue  is  more  or  less  covered  with  a  whitish  or  yellow- 
ish white  coating,  and,  although  the  appetite  is  usually  good,  the  patient 
is  often  troubled  with  flatus  and  eructations  of  gas  from  the  stomach. 
Upon  laryngoscopic  examination,  we  may  find  congestion,  confined 
generally  .to  a  small  spot  in  the  region  of  the  pain,  and  sometimes  slight 
swelling.  This  condition,  however,  is  liable  to  diminish,  disappear,  or 
change  to  other  localities  after  a  few  days,  and  there  is  nothing  char- 
acteristic in  the  appearance  of  the  parts. 

Diagxosis. — The  affection  is  apt  to  be  mistaken  for  neuralgia,  for 
enlarged  glands  or  enlarged  veins  at  the  base  of  the  tongue,  for  chronic 
follicular  tonsillitis,  glossitis,  or  pharyngitis,  for  gouty  syphilitic  or 
tubercular  sore  throat,  for  tobacco  sore  throat,  or  for  cancer.  The 
essential  points  in  the  diagnosis  are  the  uncomfortable  sensations  of  pain, 
which  change  usually  with  changes  in  the  weather,  the  existence  of  the 
rheumatic  diathesis,  and  the  absence  of  any  distinct  physical  signs. 

Chronic  rheumatic  sore  throat  is  to  be  diagnosticated  from  varicose 
veins,  enlarged  glands  at  the  base  of  the  tongue,  and  from  chronic  fol- 
licular tonsillitis,  glossitis  or  pharyngitis,  all  of  which  sometimes  present 
similar  symptoms,  by  a  careful  inspection  of  the  parts,  by  the  course  of 
the  disease,  and  by  the  results  of  treatment.  By  inspection,  we  may 
at  once  ascertain  whether  the  veins  or  glands  at  the  base  of  the  tongue 
are  enlarged,  but  unfortunately  we  cannot  tell  whether  enlargement  of 
the  glands  or  a  varicose  condition  of  the  veins  is  the  cause  of  the  symp- 
toms. Some  persons  have  these  conditions  and  yet  suffer  no  inconven- 
ience whatever,  while  in  others  serious  discomfort  arises.  Therefore,  if 
we  find  varicose  veins  or  enlarged  glands  at  the  base  of  the  tongue, 
with  evidence  of  what  seems  rheumatic  pain  in  this  locality,  these  con- 
ditions must  be  remedied  before  we  can  be  certain  they  are  not  the  cause 
of  the  trouble. 

If  careful  inquiry  reveals  evidence  of  a  rheumatic  diathesis,  it  favors 
the  diagnosis  of  rheumatic  sore  throat.  The  signs  upon  inspection  in 
chronic  follicular  tonsillitis,  glossitis,  and  pharyngitis  are  characteristic, 
and  when  they  are  found  we  may  usually  take  it  for  granted  that  the 
symptoms  of  which  the  patient  complains  are  due  to  these  diseases. 
We  might  possibly  be  mistaken  in  cases  of  this  sort,  but,  if  so,  a  failure 
to  relieve  the  symptoms  by  curing  these  conditions  would  soon  clear 
up  the  diagnosis.  Sometimes  the  diagnosis  is  extremely  difficult;  but  in 
the  majority  of  cases,  having  inquired  carefully  into  the  history  and  ex- 
cluded the  affections  here  mentioned,  we  may  come  to  an  accurate  con- 
clusion. Gouty  affections  of  the  throat  as  shown  by  S.  Solis  Cohen 
(paper  read  at  first  Pan-American  Congress)  cause  painful  symptoms 
similar  to  the  rheumatic  affection.     They  may  be  distinguished  from  the 


320  DISEASE*   OF  THE  FAUCES. 

latter  by  the  antecedent  history  and  by  the  presence  of  gouty  nodules 
and  enlargement  of  the  joints.  The  affection  may  be  distinguished 
from  syphilis  by  the  history  and  by  the  physical  signs.  In  the  early 
period  of  syphilis,  and  in  the  secondary  and  tertiary  stages,  there  are 
usually  characteristic  physical  signs  which  are  not  found  in  chronic 
rheumatic  sore  throat.  Cases  of  syphilitic  sore  throat  occur,  however, 
in  which  the  signs  are  not  characteristic,  but  in  these  I  have  never 
known  the  patient  to  complain  of  the  persistent  pain  or  discomfort 
which  characterizes  the  rheumatic  affection,  and  I  have  seen  no  reason 
for  confounding  the  two  diseases. 

"We  may  distinguish  this  sore  throat  from  tuberculosis  by  the  absence 
of  constitutional  symptoms  in  the  rheumatic  affection,  and  their  great 
prominence  in  the  tubercular  disease;  the  relatively  moderate  pain  or 
discomfort  and  the  absence  of  ulceration  in  the  former  and  in  the  latter 
the  severe  pain,  with  superficial  ulceration,  which  may  extend  over  a 
considerable  part  of  the  painful  region,  or  occasionally  deep  ulceration. 

Chronic  rheumatic  sore  throat  may  be  distinguished  from  tobacco  sore 
throat  by  the  history,  and  the  absence  of  plaques  which  appear  very  much 
as  if  the  surface  had  been  brushed  over  with  silver  nitrate;  these  are 
common  in  tobacco  sore  throat,  though  in  some  cases  we  find  no  physi- 
cal signs.  With  tobacco  sore  throat  the  patient  commonly  complains  of  a 
burning  sensation  in  the  part,  usually  relieved  soon  after  the  tobacco  is 
discontinued.  If  we  find  the  patient  a  habitual  user  of  tobacco,  if  stop- 
ping its  use  relieves  his  discomfort,  and  if  there  are  no  symptoms  of 
rheumatism  in  other  parts  of  the  body,  there  will  be  no  difficulty  in 
differentiating  the  disorders. 

It  is  often  difficult  to  distinguish  rheumatic  sore  throat  from  neural' 
gia.  The  presence  of  slight  congestion  or  swelling  is  of  considerable 
value  in  the  diagnosis,  for  in  neuralgia  there  are  no  local  signs.  In  most 
cases  of  rheumatic  sore  throat,  pressure  increases  the  pain,  while  in  neu- 
ralgia it  does  not  increase  but  may  relieve  it.  In  rheumatic  sore  throat, 
changes  of  the  weather  from  fair  or  clear  to  cloudy  and  damp  almost 
always  aggravate  the  symptoms,  while  in  neuralgia  they  have  but  little 
effect.  In  neuralgia  the  pain  is  commonly  worse  in  the  latter  part  of 
the  day,  when  the  patient  is  fatigued;  in  rheumatic  sore  throat  it  is  apt 
to  be  worse  in  the  morning,  and  is  not  particularly  increased  by  fatigue. 

The  physical  signs  distinguish  cancer.  In  most  cases  of  cancer  that  I 
have  seen,  there  have  been  in  the  early  stage  more  or  less  induration, 
with  gradually  increasing,  irregular  swelling,  and  finally  deep  ulceration. 
These  do  not  occur  in  rheumatic  sore  throat.  In  cancer,  patients  are 
not  likely  to  suffer  pain  for  any  length  of  time  before  some  of  these 
physical  changes  occur;  in  the  rheumatic  trouble,  pain  is  the  essential 
symptom,  and  the  physical  changes  are  not  marked. 

Prognosis. — We  may  expect  the  cases  to  continue  for  several  months, 
or  even  for  years.     There  is  no  danger  so  far  as  life  is  concerned. 


SORE  THROAT  OF  SMALL-POT.  321 

Treatment. — In  the  treatment,  our  first  attention  should,  be  directed 
to  prophylaxis.  With  this  in  view,  the  patient  must  be  well  clothed  and 
housed,  and  protected  from  undue  exposure.  Eheumatic  patients  should 
wear  either  woollen  or  silk  next  the  body  both  night  and  day  throughout 
the  year — light  in  summer  and  heavy  in  winter.  They  should  be  care- 
ful that  all  the  excretory  organs  perform  their  functions  properly.  They 
should  eat  sparingly  of  albuminous  substances  and  live  largely  on  vege- 
tables and  fruit;  the  vegetable  acids  are  often  advantageous,  but,  what- 
ever is  eaten,  it  is  especially  important  that  digestion  be  perfect,  so  that 
the  formation  of  ptomaines  shall  be  reduced  to  a  minimum.  For  the  local 
treatment,  sedative  or  stimulant  applications  may  be  made,  with  almost 
equal  chances  of  relief.  Applications  of  the  tincture  of  aconite  to  the 
painful  spot  four  or  five  times  a  day,  of  morphine  in  solution  or  in  powder 
will  sometimes  give  considerable  relief.-  I  have  frequently  observed  much 
benefit  from  the  application  of  such  stimulants  as  zinc  sulphate  or 
chloride  and  copper  sulphate,  in  solution ;  but  I  have  derived  most  ben- 
efit from  a  solution  of  morphine  gr.  iv.,  carbolic  acid  and  tannic  acid  aa 
gr.  xxx.,  in  glycerin  and  water  aa  "  iv.  It  is  applied  by  spray,  and  is 
frequently  given  to  the  patient  in  one-half  this  strength  to  be  used  at 
home.  In  some  cases  swabbing  the  surface  with  strong  tincture  of 
iodine  or  a  sixty-grain  solution  of  silver  nitrate  has  proved  beneficial. 
These  latter  applications  apparently  act  much  the  same  as  blisters  over 
rheumatic  joints.  The  most  important  part  of  treatment  is  the  internal 
medication.  Here  salol,  sodium  salicylate,  potassium  iodide,  guaiacum, 
Phytolacca,  and  the  oil  of  gaultherium,  one  or  all  may  be  used  at  differ- 
ent times  with  benefit;  sodium  salicylate  may  be  given  in  doses  of  seven 
to  ten  grains,  the  oil  of  gaultheria  in  doses  of  fifteen  minims,  the  ani- 
moniated  tincture  of  guaiacum  in  doses  of  a  teaspoonf  ul  administered  in 
milk  three  or  four  times  a  day.  The  resin  of  guaiac  in  lozenges  fre- 
quently repeated  is  of  considerable  value.  I  have  observed  most  benefit 
from  the  extract  of  phytolacca  and  salol  combined,  aa  gr.  iij.  to  iv.,  with 
an  occasional  laxative;  but  sometimes  they  have  been  used  conjointly 
with  potassium  iodide,  or  with  potassium  bromide  for  its  sedative  effects. 
I  occasionally  give  the  salol  in  doses  of  ten  grains.  Tinctures  of  bryonia 
and  of  cimicifuga  are  said  to  be  valuable  remedies  in  rheumatism.  I 
have  used  them  both,  with  apparently  slight  benefit  in  some  instances, 
but  the  obstinate  cases  have  done  better  under  phytolacca  and  salol  with 
occasional  use  of  the  other  remedies  already  suggested 

i 
SORE   THROAT   OF   S1TALL-POX. 

Sore  throat  of  small-pox  is  characterized  by  an  eruption  similar  to  that 
which  occurs  upon  the  skin.  In  many  cases  it  appears  before  the  cuta- 
neous eruption,  in  others  not  until  the  third  or  sixth  day  of  the  original 


322  DISEASES  OF  THE  FAUCES.- 

disease.  The  extent  of  the  eruption  will  vary  according  to  the  severity 
of  the  variola. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membrane  is  swollen,  and  the  peculiar  pustules  are  found,  but  without 
the  contracted,  depressed  centre  that  is  seen  upon  the  skin,  because  the 
covering  cannot  become  dry.  The  ulceration  of  these  pustules  fre- 
quently extends  entirely  through  the  mucous  membrane  to  the  muscular 
tissue,  which  is  more  or  less  involved  in  the  inflammatory  action.  It  is 
probably  on  this  account  that  patients  experience  such  severe  pain  in 
deglutition. 

Diagnosis. — The  diagnosis  rests  upon  that  of  the  constitutional 
disease. 

Prognosis. — The  throat  affection  per  se  is  not  dangerous;  in  serious 
cases  of  variola  there  are  liable  to  be  grave  complications  in  the  throat. 

Treatment. — Locally,  weak  astringents  and  soothing  gargles  are 
recommended. 

SORE   THROAT   OF   MEASLES. 

An  eruption  in  the  throat  is  present  in  nearly  every  case  of  measles 
as  one  of  the  first  indications  of  the  disease,  but  it  generally  disappears  in 
a  few  days.  It  is  usually  a  simple  catarrhal  inflammation  of  the  mucous 
membrane,  which  may  extend  from  the  nostrils  to  the  ultimate  bronchial 
tubes.     In  comparatively  rare  cases  there  is  a  diphtheritic  deposit. 

Symptomatology. — On  examination  of  the  fauces,  often  one  or  two 
days  before  the  disease  becomes  well  marked,  several  small  red  points 
are  noticed  on  the  palate,  pillars  of  the  fauces,  or  the  pharyngeal  wall. 
At  the  time  the  eruption  appears  upon  the  skin,  we  nearly  always  find 
much  congestion  of  the  throat.  In  diphtheritic  cases  there  is  a  fibrin- 
ous deposit  upon  the  surface.  In  some  instances  the  inflammation 
extends  deeply  into  the  tissues,  and  abscesses  result.  Many  cases  of 
measles  are  attended  by  hoarseness  due  to  laryngitis,  which  sometimes 
becomes  a  serious  complication,  particularly  where  there  is  a  fibrinous 
deposit.     The  inflammation  and  pain  often  extend  to  the  ears. 

Diagnosis. — The  diagnosis  will  depend  upon  the  cutaneous  eruption 
and  the  other  symptoms  distinguishing  measles  from  other  diseases. 

Prognosis. — So  far  as  the  throat  is  concerned,  we  expect  the  ca- 
tarrhal inflammation  to  last  seven  or  eight  days  in  the  majority  of  cases 
and  to  terminate  in  resolution.  Where  fibrinous  deposit  occurs,  the 
prognosis  is  grave,  especially  if  it  extends  to  the  larynx;  of  these  cases 
eighty  per  cent  die.  In  infancy  there  is  peculiar  danger  from  extension 
of  the  inflammation  to  the  lungs. 

Treatment. — The  treatment  for  acute  sore  throat  is  appropriate, 
but  often  no  treatment  is  necessary  except  that  which  may  be  indicated 
for  the  constitutional  disease. 


SOKE  THROAT  OF  SCARLET  FEVER.  323 

SORE  THROAT  OF  SCARLET  FEVER. 

Sore  throat  of  scarlet  fever  is  characterized  by  congestion  of  the 
palate  and  fauces,  which  occurs  early  in  the  attack  and  is  present  in 
nearly  every  case,  even  in  those  where  the  cutaneous  eruption  is  absent 
or  slight. 

Anatomical  axd  Pathological  Characteristics. — In  some  in- 
stances the  congestion  is  slight,  in  others  the  parts  are  of  a  deep  red  or 
livid  hue,  and  in  anginose  cases  there  is  much  swelling,  and  the  palate, 
pharynx,  and  tonsils  are  all  involved  in  the  inflammation  and  the  oedema. 
If  the  process  is  intense,  the  swelling  may  cause  almost  complete  closure 
of  the  throat.  The  inflammation  frequently  extends  to  the  submucous 
tissues,  resulting  in  extensive  suppuration,  and  not  infrequently  abscesses 
occur  in  other  portions  of  the  body.  In  a  large  number  of  cases  the  in- 
flammation extends  along  the  Eustachian  tube  to  the  middle  ear,  not 
infrequently  resulting  in  permanent  deafness.  In  some  cases  there  is 
diphtheritic  deposit,  but  it  has  not  been  determined  whether  this  is  a 
peculiar  phase  of  the  scarlatina  or  whether  it  is  an  association  of  the 
two  diseases. 

Symptomatology. — The  attack  is  usually  ushered  in  by  vomiting 
and  fever,  and  the  patient  complains  of  more  or  less  stiffness  of  the  jaws 
and  aching  pain  in  the  throat,  which  in  scarlatina  anginosa  may  be  very 
severe.  The  tonsils  and  mucous  membrane  are  swollen,  and  the  glands 
at  the  angles  of  the  jaws  are  often  considerably  enlarged.  In  many  cases, 
in  the  beginning  of  the  attack,  the  temperature  rises  to  105°  F.,  and  oc- 
casionally even  to  106°.  It  usually  continues  high  several  days,  and  is 
not  apt  to  disappear  before  the  ninth  or  tenth  day.  In  severe  cases, 
with  much  swelling,  resjDiration  may  be  seriously  obstructed.  The 
tongue  at  first  has  a  peculiar  strawberry  like  appearance,  due  to  promi- 
nence of  the  red  papilla?,  which  are  surrounded  by  a  white  coating,  but 
later  it  is  red  and  glazed.  The  breath  is  offensive,  particularly  in  diph- 
theritic cases,  and  in  scarlatina  anginosa.  Disturbance  of  the  stomach, 
difficulty  in  deglutition,  and  loss  of  appetite  are  among  the  common  symp- 
toms. The  degree  of  redness  and  swelling  varies  much.  In  simple 
cases  there  is  a  bright  scarlet  appearance  of  the  throat,  sometimes  ap- 
proaching a  livid  hue,  and  there  may  be  very  little  swelling,  but  in  the 
anginose  variety  the  mucous  membrane  and  tonsils  are  so  much  swollen 
as  nearly  to  close  the  fauces.  In  many  cases,  during  the  first  or  second 
day  a  thin  pseudo-membranous  deposit  occurs  upon  the  inflamed  tissues, 
and  in  some  this  becomes  thicker  and  darker  in  color  and  finally  acquires 
the  appearance  of  the  membrane  in  diphtheria.  Occasionally  in  the 
beginning  the  symptoms  and  signs  are  those  of  tonsillitis  only. 

Diagnosis. — The  disease  is  to  be  distinguished  from  acute  sore 
throat,  from  tonsillitis,  and  from  diphtheria.  The  essential  points  in 
the  diagnosis  are  the  history  and  characteristic  eruption  of  scarlet  fever. 


324  DISEASES  OF  THE  FAUCES. 

The  appearances  are  much  the  same  in  acute  sore  throat  as  in  scar- 
latina during  the  first  two  or  three  days,  but  the  constitutional  symp- 
toms are  usually  lighter  and  the  subsequent  history  different. 

There  is  apt  to  he  more  swelling  in  tonsillitis,  which  is  often  con- 
fined to  one  side,  and  there  is  no  cutaneous  eruption  excepting  in  rare 
instances. 

A  thick  false  membrane  occurs  early  in  diphtheric,  while  the  tempera- 
ture is  comparatively  low  (101°  to  102°  F.),  and  other  constitutional  symp- 
toms are  not  severe;  in  scarlatina  there  is  high  fever  at  first.,  with  little, 
if  any,  fibrinous  deposit ;  and  thick  pseudo-membrane,  if  developed  at 
all,  does  not  often  occur  until  late  in  the  disease. 

Prognosis. — In  mild  cases  the  throat  symptoms  usually  disappear  in 
from  six  to  ten  days,  but  in  scarlatina  anginosa  or  in  malignant  cases  the 
throat  may  not  be  involved  until  the  eighth  or  ninth  day.  but  then  exten- 
sive swelling  takes  place  in  the  course  of  a  few  hours,  and  in  a  short  time 
extensive  pseudo-membranous  deposits  may  occur.  In  simple  cases  there 
is  no  danger  so  far  as  the  throat  is  concerned:  twenty-five  per  cent  of 
the  anginose  cases  die,  and  of  diphtheritic  cases  fifty  per  cent  are  fatal. 

Treatment. — Emollient  applications  and  antiseptic  gargles  or  sprays 
are  usually  recommended.  Solutions  of  carbolic  acid  gr.  v.  to  viij.  ad 
5  i.  of  glycerin  and  water,  weak  solutions  of  potassium  permanganate 
gr.  v.  to  x.  ad  3  i.,  or  some  of  the  other  antiseptics  may  be  employed  for 
this  purpose.  As  the  patient  progresses  toward  recovery,  the  ferrugi- 
nous and  bitter  tonics  will  be  found  beneficial.  If  there  is  much  depres- 
sion, alcoholic  stimulants  are  indicated,  and  should  be  given  freely. 
Potassium  chlorate  has  been  recommended  highly  in  the  treatment  of 
the  throat  affection  of  scarlatina,  in  quantities  proportionate  to  the  age 
of  the  patient:  for  an  adult,  gr.  xl.  to  lx.  daily  in  divided  doses.  It 
should  be  promptly  discontinued  if  it  causes  irritation  of  the  kidneys. 

SIMPLE    MEMBRANOUS    SORE   THROAT. 

Synonyms. — Herpetic  sore  throat,  aphthous  sore  throat. 

This  is  a  form  of  sore  throat  characterized  by  the  occurrence  of  small 
blisters  and  herpetic  patches  in  the  fauces  and  on  the  pharynx,  which,  after 
a  short  time,  rupture,  and  the  surface  becomes  covered  with  an  inflamma- 
tory deposit  or  false  membrane  similar  to  the  membrane  in  diphtheria, 
though  less  dense  and  much  more  friable.  The  affection  occurs  most  fre- 
quently in  damp  climates  and  in  the  colder  months  of  the  year,  particularly 
when  there  are  sudden  changes,  as  in  the  spring  or  fall.  It  is  more  fre- 
quent in  women  and  children  than  in  men,  and  is  observed  oftenest 
among  those  who  are  naturally  delicate.  It  occurs  frequently  during 
epidemics  of  diphtheria,  and  is  occasionally  associated  with  tuberculosis 
or  syphilis. 

Anatomical  and  Pathological  Characteristics. — In  the  begin- 


SIMPLE  MEMBRANOUS  SORE  THROAT.  325 

iiiug  of  the  attack  there  are  found  several  small  distended  follicles, 
about  the  size  of  a  pin's  head,  with  more  01*  less  reddening  and  tumefac- 
tion of  the  surrounding  mucous  membrane.  These  may  occur  singly  or 
in  patches, and  may  terminate  in  one  of  three  ways:  first,  by  resorption, 
in  which  case  they  may  disappear  in  two  or  three  days  and  the  mucous 
membrane  may  be  left  in"  a  healthy  condition;  second,  they  may  burst 
and  small  deep  ulcers  may  remain,  which  may  either  heal  rapidly  in 
twenty-four  to  forty-eight  hours,  or  may  become  covered  with  membra- 
nous deposit;  third,  several  of  these  ulcers  may  coalesce,  forming  a  large 
patch  which  becomes  covered  over  with  false  membrane.  I  have  fre- 
quently seen,  in  the  beginning  of  such  an  attack,  patches  five  to  ten  mil- 
limetres in  diameter,  covered  with  this  false  membrane,  which  to  all 
appearances,  were  not  preceded  by  the  small  inflamed  follicles. 

Etiology. — The  disease  is  attributed  to  exposure  and  to  certain 
miasmatic  influences  not  well  understood.  In  occasional  cases  occurring 
at  the  menstrual  period  it  is  attributed  to  uterine  disturbances.  Certain 
epidemic  influences  appear  to  favor  the  disease,  for  it  is  more  frequent 
when  diphtheria  is  prevalent. 

Symptomatology. — The  attack  usually  comes  on  with  a  slight  chill, 
followed  by  fever  and  attended  by  severe  pain  in  the  throat.  For  the 
first  clay  or  two  the  patient  complains  only  of  the  symptoms  of  simple 
acute  sore  throat.  Usually  there  is  first  a  sensation  of  dryness,  and  after 
a  short  time  a  severe  burning  or  smarting  pain,  which,  so  far  as  we  can 
judge  from  the  patient's  description,  is  more  intense  than  that  of  any 
other  acute  affection  of  the  throat.  This  pain  sometimes  radiates  toward 
the  ears,  and  is  said  to  extend  occasionally  to  the  nasal  cavities,  and  in 
rare  instances  to  the  larynx.  Xearly  always  we  find  a  herpetic  eruption 
upon  the  lips  at  some  time  during  the  course  of  the  disease.  The  fever 
is  occasionally  very  high  for  a  few  days;  in  other  instances  there  is  but 
very  little  elevation  of  temperature.  The  pulse  is  accelerated ;  the  tongue 
is  usually  flabby,  indented  at  the  edges  by  the  teeth  and  covered  with  a 
thick,  white  fur;  there  is  great  difficulty  in  swallowing,  because  of  the 
pain,  which,  however,  varies  with  the  location  of  the  diseased  follicles 
or  patches.  Upon  inspecting  the  parts,  we  find  small  inflamed  follicles 
or  pustules,  often  not  more  than  two  or  three  in  number,  on  the  palate, 
fauces,  or  the  side  of  the  mouth;  or  in  place  of  these  small  ulcers,  or 
ulcers  covered  with  false  membrane;  sometimes  the  pustules  and  ulcers 
are  found  together,  because  the  inflamed  follicles  come  out  in  successive 
groups  for  four  or  five  days.  Often  early  in  the  attack  there  is  general 
redness  of  the  parts  with  localized  patches  of  deeper  congestion,  which 
may  appear  before  the  pustules  are  developed.  In  the  majority  of  cases, 
the  most  pronounced  physical  sign  will  be  the  presence  of  one  or  more 
patches,  round  or  oval  in  form,  usually  from  five  to  ten  millimetres 
in  diameter  but  sometimes  a  little  larger,  and  covered  by  a  thin  yellow- 
ish white  false  membrane  which  can  be  readily  removed  with  a  swab 


326  DISEASES  OF  THE  FAUCES. 

of  cotton.  These  are  found  on  the  side  of  the  tongue,  fauces,  or  inner 
surface  of  the  cheeks,  and  sometimes  even  upon  the  lips.  Under  this 
membrane  we  may  find  an  irritated  and  easily  bleeding  surface.  In 
some  instances,  on  removing  it  we  find  the  mucous  membrane  beneath 
in  a  perfectly  healthy  condition.  Occasionally  early  in  the  attack  there 
is  a  thin  membrane  spread  over  the  tonsils,  with  very  little  erosion. 
During  the  attack  false  membrane  will  sometimes  form  upon  sores  in 
other  parts  of  the  body.  Usually  the  disease  is  more  pronounced  upon 
one  side  only,  but  it  may  spread  over  both  sides  and  the  pharynx,  al- 
though it  seldom  or  never  extends  forward  upon  the  hard  palate.  The 
membrane  is  not  apt  to  be  continuous  like  that  of  diphtheria,  but  occurs 
in  scattered  patches. 

Diagnosis. — The  disease  is  liable  to  be  mistaken  for  diphtheria  only. 
Late  in  the  attack  it  may  sometimes  be  distinguished  from  diphtheria  by 
the  slight  constitutional  symptoms;  though  often  there  is  high  fever  in 
the  beginning  of  the  attack.  In  simple  membranous  sore  throat,  herpes 
appears  upon  the  lips  during  the  first  three  or  four  days;  not  so  in  diph- 
theria. The  membrane,  in  membranous  sore  throat,  is  superficial  and 
thin,  about  one  millimetre  in  thickness,  and  it  may  be  easily  detached, 
leaving  beneath  simply  an  excoriated,  congested,  or  sometimes  healthy 
surface.  In  diphtheria  the  membrane  is  three  or  four  millimetres  in 
thickness,  is  detached  with  difficulty  if  at  all,  seeming  to  extend  into  the 
original  tissues  and  be  a  part  of  them,  and  leaves  an  irregular  and  deeply 
ulcerated  surface.  Membranous  sore  throat  is  occasionally  followed  by 
paralysis,  leading  one  to  question  the  accuracy  of  the  diagnosis.  In 
some  cases  the  symptoms  and  signs  are  clearly  those  of  membranous  sore 
throat,  but  after  a  few  days  diphtheria  becomes  implanted  upon  it,  giving 
all  the  characteristics  of  the  latter  disease.  Some  authors  believe  these 
affections  identical,  but  the  weight  of  authority  is  against  this  view. 

Pbogstosis. — The  disease  maybe  expected  to  terminate  in  recovery 
in  from  eight  to  ten  days;  there  is  sometimes,  however,  a  tendency  to 
recurrence.  We  may  assure  the  friends  that  there  is  no  danger  from 
the  disease  alone,  but  it  is  well  to  warn  them  of  the  possibility  that  diph- 
theria may  become  implanted  upon  it. 

Treatment. — In  the  treatment  of  the  disease  a  medium  dose  of 
magnesium  sulphate  or  citrate  is  desirable  early.  This  may  be  followed 
by  quinine  and  anodynes  to  relieve  pain.  Arsenious  acid  in  small  doses 
has  been  highly  recommended.  I  have  given  potassium  bromide  inter- 
nally, for  its  anodyne  effects,  with  benefit,  and  it  is  recommended  in 
solution  as  an  inhalation  from  a  steam  atomizer.  The  vapor  of  com- 
pound tincture  of  benzoin,  3  i.  ad  0  i.  of  hot  water,  is  also  recommended 
as  an  inhalation.  Weak  antiseptic  gargles  of  potassium  permanganate, 
carbolic  acid,  listerine,  or  Dobell's  solution  are  useful  to  clear  the  throat 
of  the  mucus.  Charles  E.  Sajous  recommends  that  the  false  membrane 
be  detached  and  the  exposed  surface  touched  every  three  hours  with  a 


SIMPLE  MEMBRANOUS  SORE  THROAT.  327 

ten  grain  solution  of  potassium  permanganate  (Diseases  of  the  Xose 
and  Throat,  1885).  I  have  derived  most  benefit  from  a  solution  of 
morphine,  tannic  acid,  and  carbolic  acid  (Form.  139).  Applied  to  the 
ulcerated  surface,  this  will  often  give  relief  for  ten  or  twelve  hours.  Oc- 
casionally solutions  of  silver  nitrate  act  well,  but  in  some  cases  I  have 
been  unable  to  find  anything  that  would  give  much  relief.  The  free 
use  of  demulcents,  such  as  rice  water,  an  infusion  of  slippery  elm  bark, 
or  flaxseed  tea,  is  soothing  to  the  parts.  With  these  may  be  combined 
a  little  lemon  juice  if  more  agreeable  to  the  patient.  Potassium  chlo- 
rate has  been  highly  recommended  for  this,  as  it  has  for  nearly  every 
other  disease  of  the  throat:  but  in  every  instance  in  which  I  have  given 
it  trial,  it  has  caused  intolerable  smarting.  In  cases  subject  to  frequent 
recurrence  of  this  disease,  J.  Solis  Cohen  especially  recommends  touch- 
ing the  spots  with  dilute  nitric  acid.  Good  diet  is  to  be  recommended, 
and  the  patient  must  avoid  exposure. 


CHAPTER  XIX. 

DISEASES   OF   THE   FAUCES.— Continued. 

DIPHTHERIA. 

Synonyms. — Diphtheritis,  angina  diphtheritica,  angina  membranosa. 

Diphtheria  is  a  specific  contagions  disease,  characterized  by  pro- 
nounced constitutional  symptoms  and  inflammation  of  the  mucous  mem- 
brane of  the  fauces  and  upper  air  passages,  with  exudation  of  inflam- 
matory lymph,  which  rapidly  becomes  formed  into  false  membrane.  It 
has  long  been  recognized  by  the  best  authorities  as  one  of  the  zymotic 
fevers.  Many  English  authorities,  with  whom  I  am  fully  in  accord,  look 
upon  this  as  a  constitutional  disease  with  local  manifestations,  but  many 
continental  authors  and  some  American  writers  regard  it  as  a  primary 
local  affection  with  secondary  constitutional  manifestations.  The  dis- 
ease occurs  sporadically,  endemically  or  epidemically,  and  appears  to 
have  no  geographical  limitations,  but  is  most  frequent  in  temperate 
climates.  It  is  most  common  in  cold,  damp  weather  and  during  the 
spring  or  fall  months,  but  is  often  seen  in  winter,  and  not  infreqnently 
during  warm  weather.  Lennox  Browne  states  that  those  who  have 
enlarged  tonsils  are  especially  receptive  of  the  contagium  (Diseases  of  the 
Throat,  2d  ed.).  The  great  majority  of  cases  are  observed  in  children 
under  six  years,  but  adults  are  not  exempt.  The  disease  is  not  often 
observed  twice  in  the  same  individual. 

Anatomical  and  Pathological  Characteristics. — In  the  begin- 
ning of  diphtheria  there  is  congestion  of  the  mucous  membrane  of  the 
fauces,  usually  uniform,  but  occasionally  in  patches.  This  may  gradually 
extend  to  the  entire  mucous  membrane  of  the  throat,  and  it  is  soon  fol- 
lowed by  the  exudation  of  inflammatory  lymph,  which  in  most  instances 
proceeds  within  a  few  hours  to  the  formation  of  false  membrane.  The 
deposit  originates  generally  in  one  place  and  gradually  extends  to  the  sur- 
rounding tissues,  but  it  may  commence  in  several  spots  at  the  same  time. 
It  is  usually  first  found  upon  one  or  both  tonsils,  from  which  it  grad- 
ually extends,  according  to  the  severity  of  the  disease,  to  the  palate, 
pharynx,  naso-pharynx,  and  other  portions  of  the  air  passage.  Rarely, 
it  is  found  lining  the  oesophagus  and  other  parts  of  the  alimentary  canal. 
Wounds  upon  the  skin  are  liable  to  become  covered  by  the  same  pro- 
cess. Extension  of  the  disease  to  the  air  passages  gives  rise  to  diph- 
theritic croup,  or  pulmonary  collapse.     Blood  clots  in  the  ventricles  of 


DIPHTHERIA.  329 

the  heart  or  large  arteries  are  not  infrequently  found  in  post-mortem 
examinations.  Enlarged  lymphatic  glands  are  common,  occasionally  sup- 
purating, and  in  the  majority  of  cases  the  kidneys  are  congested  or  actu- 
ally inflamed.  Various  bacteria  have  been  found  in  the  diphtheritic 
membrane,  but  most  or  all  of  these  inhabit  the  mucous  membrane  of  the 
mouth  of  healthy  individuals. 

Etiology. — The  disease  is  generally  conceded  to  be  contagious,  and 
may  be  communicated  from  man  to  the  lower  animals  and  vice  versa  ;  it 
is  believed  by  most  physicians  to  be  due  to  a  specific  micro-organism. 
The  researches  of  T.  M.  Prudden  {American  Journal  of  Medical  Sciences, 
April  and  May,  1889)  pointed  to  a  streptococcus  as  the  probable  cause 
of  diphtheria,  but  the  results  of  his  later  investigations  harmonize  with 
those  of  most  bacteriologists,  who  now  attribute  the  disease  to  the 
Klebs-Lofner  bacillus.  This  is  a  microscopic  rod  about  the  length  of 
the  tubercle  bacillus,  but  twice  its  thickness.  It  is  usually  more  or  less 
bent,  with  rounded  ends,  one  or  botb  of  which  may  be  thickened,  giving 
the  club  or  dumb-bell  appearance;  it  is  immobile  and  contains  no  spores. 

These  bacilli  do  not  readily  absorb  the  common  aniline  stains,  but  are 
easily  colored  by  a  solution  of  Loffler's  methylin-blue,  the  coloration  often 
being  most  intense  at  the  extremities.  According  to  Armand  Euffer 
{British  Medical  Journal,  July  26th,  1890),  these  bacilli  are  found  most 
abundantly  in  the  superficial  portions  of  the  false  membrane,  and  nearly 
all  experiments  go  to  prove  that  they  do  not  usually  enter  the  lym- 
phatics or  blood  vessels;  therefore,  of  itself  the  bacillus  is  innocuous, 
but  it  produces  a  virulent  ptomaine  which  is  readily  absorbed  and  which 
may  cause  the  constitutional  symptoms  of  the  disease.  Numerous  clin- 
ical observations  and  experiments,  however,  have  demonstrated  with  an 
equal  degree  of  certainty  that  pseudo-membranous  inflammation  is  often 
produced  independent  of  the  Klebs-Lofner  bacillus,  as,  for  example, 
that  resulting  from  surgical  operations  in  the  throat;  or  from  injury 
inflicted,  boiling  water,  steam,  cantharides,  chlorine,  and  ammonia;  or 
the  exudative  inflammations  supposed  to  be  of  microbic  origin,  fre- 
quently observed  in  scarlet  fever  and  measles.  This  latter  variety  of 
inflammation  is  termed  by  Smith  and  Warner  {Annual  of  the  Univer- 
sal Mediccd  Sciences,  1891)  pseudo-diphtheria,  and,  as  stated  by  them, 
can  only  be  distinguished  from  true  diphtheria  due  to  the  Klebs- 
Lofner  bacillus  by  the  fact  that  it  is  not  followed  by  paralysis  and  is 
not  attended  by  a  peculiar  form  of  albuminuria  unassociated  with 
dropsy  or  uraemic  poisoning.  The  necessity  for  assuming  that  there  are 
two  varieties  of  diphtheria,  one  produced  by  the  Klebs-Loffler  bacillus, 
the  other  by  other  bacteria,  seems  to  justify  the  statement,  that  the 
identity  of  the  specific  micro-organism,  believed  to  cause  the  disease,  is 
as  yet  uncertain.  Eoux  and  Yersin  {U  Union  Medicate,  Paris;  Annual 
of  the  Universal  Medical  Sciences,  1892)  report  that  in  the  secretions 
from  the  mouths  of  fifty  healthy  children,  living  in  a  village  near  the 


330  DISEASES  OF  THE  FAUCES. 

coast,  where  diphtheria  was  unknown,  they  found  in  52  per  cent  a  bacillus 
morphologically  identical  with  the  ordinary  Klebs-Loffler  bacillus  and 
behaving  in  cultures  exactly  like  the  latter,  excepting  in  the  number  of 
its  colonies.  This  they  believe  to  be  the  Klebs-Loffler  bacillus  in  a  non- 
virulent  condition. 

There  can  be  no  doubt  that  primary  simple  inflammation  favors  the 
production  of  diphtheria,  but  it  is  doubtful  whether  it  is  ever  in  itself 
capable  of  producing  the  disease.  Infection  may  occur  from  another 
patient  or  from  articles  contaminated  by  him.  Commonly  its  origin  is 
referred  to  the  use  of  certain  drinking  water  or  milk  or  the  inhala- 
tion of  emanations  from  sewers,  or  from  damp,  unhealthy  cellars  or 
decaying  refuse.  The  most  common  predisposing  cause,  I  believe,  is  the 
exposure  of  young  children  to  the  chilly  atmosphere  of  our  houses  in 
the  spring  and  fall  months  or  during  the  warmer  portions  of  winter, 
when  fires  are  not  considered  necessary  by  adults. 

Symptomatology. — After  a  period  of  incubation  varying  from  one 
to  eight  days,  the  disease  usually  commences  in  young  children  with  well- 
marked  constitutional  symptoms,  such  as  headache,  drowsiness,  more  or 
less  fever,  thirst,  vomiting  or  diarrhoea,  and  stiffness  of  the  neck  at  the 
angle  of  the  jaw,  with  more  or  less  soreness  of  the  throat.  In  older 
children  and  adults,  the  invasion  is  more  gradual.  In  from  twelve  to 
thirty-six  hours  from  the  first  symptoms,  the  false  membrane  can 
usually  be  detected  in  the  throat,  and  in  some  cases  it  is  deposited 
in  considerable  quantities  before  the  person  is  thought  to  be  ill.  The 
patient  usually  complains  of  a  sensation  of  dryness  and  a  desire  to  hawk 
and  clear  the  throat,  with  some  pain,  especially  upon  deglutition.  Ex- 
ceptionally an  erythematous  eruption  makes  its  appearance  on  the  skin 
during  the  first  few  hours  of  the  affection.  The  pulse  is  rapid,  small, 
and  feeble,  and  as  the  disease  progresses  it  may  be  intermittent. 
"Finally,  it  grows  exceedingly  feeble  and  slower  than  normal  as  death 
from  exhaustion  approaches.  The  temperature  usually  rises  to  101°  or 
102°  F.  during  the  first  hours  of  the  attack,  but  with  the  deposit  of 
false  membrane  it  generally  falls  and  may  even  become  subnormal. 
After  two  to  four  days  it  may  again  rise,  indicating  in  favorable  cases 
suppuration  and  separation  of  the  false  membrane,  or  in  others  an  ex- 
tension of  the  disease  to  the  larynx,  lungs,  kidneys,  or  other  parts.  In 
the  later  stages  of  the  disease,  sudden  fall  to  the  subnormal  point  is  a 
serious  symptom  indicative  of  failing  strength.  The  voice  is  often 
altered,  weak,  and  hoarse,  even  before  the  larynx  is  affected,  but  when 
false  membrane  has  extended  to  the  glottis  hoarseness  becomes  more 
pronounced  or  the  voice  may  be  entirely  lost.  With  involvement  of  the 
larynx,  dyspncea  appears,  and  it  may  steadily  or  suddenly  increase,  ag- 
gravated, however,  from  time  to  time,  by  spasms  of  the  glottis.  Respi- 
ration becomes  noisy  and  stridulous,  there  is  an  irritating  laryngeal 
cough,  and  with  the  spasms  of  the  glottis  all  the  symptoms  of  suffoca- 


DIPHTHERIA.  331 

tion  appear;  the  false  membrane  may  be  loosened,  and  fragments  of 
considerable  size  are  often  expectorated.  Sometimes  complete  casts 
of  the  trachea  or  bronchi  are  thrown  off  in  this  way.  When  the  disease 
extends  to  the  naso-pharynx  and  nostrils,  there  is  obstruction  of  the 
nose  and  a  fetid,  sanious  discharge,  frequently  accompanied  in  grave 
cases  by  epistaxis.  The  tongue  is  coated  with  thick,  yellowish  fur,  and 
the  breath  has  a  peculiar  odor  most  characteristic  of  the  disease.  In 
malignant  cases  this  odor  is  so  pronounced  as  to  permeate  the  entire 
apartment.  The  tongue  is  coated  from  the  first,  and  in  unfavorable 
cases  it  becomes  harsh  and  dry  and  covered  with  a  thick,  dark  coat. 
The  appetite  is  poor  and  in  severe  cases  may  be  entirely  lost;  nausea  and 
vomiting  are  not  infrequent,  particularly  when  the  kidneys  are  in- 
volved. Swelling  of  the  cervical  glands  occurs  in  most  severe  cases, 
especially  at  the  angles  of  the  jaw;  the  submaxillary  and  parotid  glands 
are  sometimes  involved.  The  throat  is  at  first  deeply  congested,  but 
soon  the  false  membrane  is  deposited,  primarily  upon  one  or  both 
tonsils.  In  the  beginning,  this  membrane  is  white  in  color,  but  it  soon 
becomes  yellowish,  and  with  the  advance  of  the  disease  grayish,  brownish, 
or  even  almost  black.  It  has  the  appearance  of  involving  the  mucous 
membrane  and  being  slightly  elevated  above  the  surface.  If  the  mem- 
brane is  exfoliated  or  forcibly  removed,  an  ulcerated,  granular,  and 
bleeding  surface  remains,  which  is  again  soon  covered  with  false 
membrane.  This  membrane  is  firmly  adherent  to  the  surface,  and  can- 
not be  removed  by  brushing  with  a  swab  of  cotton,  as  can  the  mucus 
which  collects  in  other  forms  of  sore  throat.  With  the  laryngoscope,  false 
membrane  may  be  discovered  in  the  naso-pharynx  or  the  larynx.  When 
the  latter  becomes  obstructed,  a  sinking  in  of  the  softer  portions  of  the 
chest  is  noticed  with  each  inspiration,  well  marked  above  and  below  the 
clavicles,  but  especially  at  the  lower  part  of  the  sternum.  As  the  glottis 
becomes  more  and  more  obstructed,  the  skin  is  pallid  and  bathed  in 
cold  perspiration,  the  lips,  ears,  and  extremities  appear  blue;  the  pa- 
tient grows  restless,  throwing  himself  from  side  to  side  of  the  bed 
every  few  moments,  and  with  the  paroxysms  of  dyspnoea  he  throws  his 
arms  about  and  clutches  at  his  throat  in  the  vain  effort  to  obtain  more 
air.  As  the  disease  progresses,  the  signs  of  carbonic  acid  poisoning 
are  more  and  more  marked,  the  patient  becomes  listless  and  drowsy, 
and  finally  dies  in  a  comatose  condition;  or  he  may  be  suddenly  carried 
off  by  a  spasm  of  the  glottis,  a  general  convulsion,  or  heart  failure. 

Diagnosis. — Diphtheria  may  be  confounded  with  simple  catarrhal, 
or  rheumatic  pharyngitis;  tonsillitis  simple  or  follicular;  erysipelas, 
scarlatina,  and  other  constitutional  diseases,  or  with  simple  membranous 
sore  throat.  The  essential  points  in  the  diagnosis  are  the  history,  the 
rapid  progress  of  the  case,  the  appearance  of  firmly  adherent  whitish  or 
yellowish  gray  membrane  in  the  throat,  and  the  condition  of  the  urine. 

In  catarrhal  or  rheumatic  pharyngitis  the  temperature  is  higher, 
the  pain  is  greater,  and  there  is  no  formation  of  false  membrane. 


DISEASES   OF  THE  FAUCES. 

In  erysipelas  of  the  throat  the  eruption  is  developed  more  slowly,  and 
the  history  is  entirely  different,  Scarlatina  is  developed  more  rapidly, 
the  temperature  rises  early  to  1<>3  or  105  F.  and  remains  so  for  several 
days;  in  diphtheria  it  seldom  rises  higher  than  101°  or  102°  F.  in  the 
beginning.  In  scarlatina,  after  a  short  time  a  characteristic  rash  ap- 
pears upon  the  skin;  the  appearance  of  the  throat  is  not  greatly  different 
in  the  commencement,  though  the  congestion  is  generally  more  uniform 
than  in  diphtheria,  and  in  uncomplicated  cases  there  is  no  false  mem- 
brane. 

In  tonsillitis  the  temperature  is  much  higher,  the  disease  comes  on 
more  rapidly,  there  is  more  pain  in  the  throat,  and  usually  there  is 
difficulty  in  opening  the  mouth  which  does  not  occur  in  diphtheria.  In 
simple  tonsillitis  there  is  more  swelling,  but  no  deposit  of  inflammatory 
lymph.  The  history  of  follicular  tonsillitis  is  essentially  that  of  the 
simple  form,  hut  numerous  yellowish  points  or  spots  appear  upon  the 
tonsils  at  the  orifices  of  the  lacuna?.  These,  however,  differ  from  the 
appearance  of  diphtheritic  membrane,  in  that  they  are  more  numerous, 
smaller,  are  not  elevated  above  the  surface  of  the  mucous  membrane, 
are  confined  to  the  tonsil  in  the  majority  of  cases,  and  never  found  upon 
the  palate. 

Simple  membranous  sore  throat,  if  seen  at  the  beginning  of  the 
attack  when  the  vesicles  first  appear,  is  not  very  likely  to  be  mistaken 
for  diphtheria;  but  if  the  patient  does  not  come  under  observation  until 
two  or  three  days  later,  the  diagnosis  may  be  difficult  or  even  impossible, 
especially  if  diphtheria  is  prevalent  at  the  same  time.  In  most  cases  of 
membranous  sore  throat  the  patient  complains  of  much  more  pain  and 
the  false  membrane  is  more  easily  detached  and  is  much  thinner  than  in 
diphtheria.  In  some  cases  a  herpetic  eruption  in  the  throat  and  on  the 
lips  reveals  the  true  nature  of  the  disease. 

In  phlegmonous  or  erysipelatous  sore  throat  the  patient  suffers  more 
pain,  the  temperature  is  higher,  and  the  tissues  are  very  oedematous  and 
livid,  the  invasion  and  course  of  the  disease  are  different,  and  diphther- 
itic membrane  is  absent. 

Prognosis. — The  prognosis  is  always  grave,  for  no  matter  how  mild 
tiie  case  in  its  commencement,  it  is  impossible  to  predict  what  the  com- 
plications may  be  before  it  has  run  its  course;  and  although  the  large 
majority  of  cases  recover,  it  is  never  safe  to  make  a  favorable  prognosis 
without  warning  the  friends  of  possible  danger.  In  fatal  cases  death 
occasionally  occurs  within  twenty-four  hours  after  the  first  appearance 
of  the  disease,  and  in  the  majority  the  fatal  termination  is  within  five 
days;  but  in  some  the  struggle  for  life  continues  five  or  six  weeks  be- 
fore the  patient  succumbs.  In  favorable  cases  convalescence  is  usually 
established  about  the  end  of  the  third  week,  but  especially  where  com- 
plications have  existed,  the  duration  may  be  much  longer.  As  a  rule, 
the  younger  the  patient  the  greater  the  danger.  Among  the  symptoms 
and  signs  indicative  of  gravity  are  deposits  of  membrane  in  the  nose, 


DIPHTHERIA.  333 

pharynx,  or  intestines;  extreme  pain  in  the  ears  or  throat,  pnrpuric 
spots  on  the  skin,  epistaxis,  and  other  hemorrhages,  persistent  anorexia, 
vomiting,  diarrhoea,  and  suppression  of  the  urine.  Asthenia,  a  typhoid 
condition,  or  signs  of  heart  failure  are  often  precursors  of  death.  When 
the  larynx  is  involved,  it  is  probable  that  without  surgical  interference 
the  mortality  reaches  ninety-five  per  cent,  and  with  it  about  sixty  per 
cent.  Patients  not  infrequently  die  suddenly  of  heart  failure,  and  often 
the  pulse  becomes  weak  and  intermittent  on  the  slightest  effort,  and 
clearly  points  ,to  the  necessity  of  relieving  the  heart  from  all  undue  ex- 
ertion in  order  to  save  the  patient's  life. 

As  the  case  progresses  toward  recovery,  the  appetite  returns,  the  tem- 
perature diminishes,  difficulty  with  respiration  disappears,  and  articula- 
tion again  is  normal;  however,  the  difficulty  in  swallowing  of  ten  becomes 
greater,  from  exposure  of  ulcerated  surfaces  which  cause  more  pain  on 
deglutition,  or  from  paresis  of  the  deglutitory  muscles.  Not  infrequently 
paralytic  symptoms  follow  the  attack  closely,  about  the  end  of  the  third 
week,  but,  except  in  cases  where  the  respiratory  or  circulatory  centres  are 
involved,  recovery  usually  occurs,  though  it  may  be  delayed  for  several 
weeks  or  even  months,  Owing  to  danger  from  the  sequela?,  especially 
heart  failure,  we  can  never  fully  relieve  the  anxiety  of  friends  until  our 
patient  has  been  well  for  about  three  weeks. 

Teeatmext. — There  are  few  diseases  in  which  the  methods  of  treat- 
ment recommended  are  more  numerous,  a  fact  which  is  explained  by  the 
inutility  of  a  great  majority  of  the  means  adopted.  So  much  depends 
upon  the  nature  of  the  epidemic,  the  condition  of  the  patient  when  first  at- 
tacked, and  his  surroundings,  that  it  is  very  difficult  to  arrive  at  accurate 
conclusions  regarding  the  effects  of  remedies.  .  During  the  earlier  por- 
tion of  many  epidemics  a  large  proportion  of  those  attacked  die,  and 
therefore  whatever  remedies  have  been  used  seem  to  be  fruitless ;  whereas 
in  the  latter  part  of  the  same  epidemic  a  large  majo:'ity  of  the  cases 
recover,  no  matter  what  treatment  is  employed,  and  the  remedies  in  use 
at  the  time  get  the  credit.  Many  physicians  have  favorite  prescriptions, 
on  which  they  place  great  reliance  until  called  upon  to  treat  serious 
cases;  then,  unfortunately,  all  methods  often  fail  and  the  physician 
comes  to  believe  that  little  can  be  accomplished  by  treatment.  The 
methods  to  be  adopted  are:  first,  prophylactic;  second,  dietetic;  third, 
local;  fourth,  internal  or  general;  fifth,  operative. 

Prophylaxis  is  of  prime  importance  in  relation  to  diphtheria.  The 
most  useful  measures  consist  of  thorough  ventilation  and  proper  drainage, 
pure  water  supply,  proper  clothing,  and  proper  heating  of  living  apart- 
ments, and  as  far  as  possible  protection  especially  of  children,  from  the 
contagium.  It  must  be  remembered  that  sometimes  the  specific  poison 
may  be  carried  from  one  to  another  by  domestic  animals,  or  in  the  cloth- 
ing, or  about  the  person  of  one  who  has  been  visiting  the  sick  or  at- 
tending funerals.     As  the  disease  is  generally  prevalent  during  the  cool 


334  DISEASES  OF  THE  FAUCES. 

and  damper  portions  of  the  year,  when  the  need  of  fires  is  not  appreci- 
ated by  adults,  it  is  of  special  importance  that  children  be  cared  for 
at  this  time,  that  they  have  proper  clothing,  and  that  a  suitable 
temperature  of  the  house  be  maintained.  It  has  appeared  to  me 
that  during  the  spring  and  fall  months  children  are  much  more 
liable  to  catch  cold  and  consequently  to  have  diphtheria,  in  the  house 
with  a  temperature  of  about  65°  to  68°  F.  than  when  the  temperature  is 
even  colder.  An  effort  should  be  made  to  maintain  the  temperature  of 
the  house  as  nearly  as  possible  at  70°  P.,  and  children  should  not  be 
allowed  to  run  about  in  their  night  clothing  morning  ami  evening  or  to 
stand  about  while  dressing  with  the  temperature  at  from  55°  to  65°  F.,  as 
it  is  liable  to  be.  They  need  to  be  carefully  protected  at  night  from 
exposure  due  to  kicking  off  the  bedding.  If  the  disease  has  made  its 
appearance  in  a  household,  other  children  of  the  family  must  be  pre- 
vented from  all  intercourse  with  the  patient,  and  the  sick  one  should  be 
given  an  airy,  comfortable  room,  which  may  be  freely  ventilated  without 
exposing  the  patient  to  draughts.  Daniel  E.  Brower,  of  Chicago,  advo- 
cates an  excellent  method  of  ventilation  during  an  attack  of  this  dis- 
ease, consisting  of  changing  the  patient  two  or  three  times  a  day  from 
one  room  to  another,  the  vacated  room  being  thoroughly  ventilated  in 
the  interim.  It  is  a  useful  precaution  to  hang  over  the  door  of  the  sick- 
room sheets  kept  moistened  with  carbolic  acid  to  prevent  contamination 
of  the  air  of  the  house  during  the  necessary  opening  of  the  door.  The 
temperature  of  the  sick  room  should  be  kept  at  from  70°  to  75°  F.,  and  in 
all  cases  an  abundant  supply  of  fresh  air  provided.  All  utensils  or 
clothing  used  in  the  room  should  be  disinfected  or  destroyed,  and  finally 
the  room  should  be  thoroughly  fumigated  before  it  is  again  used. 

Orancher,  of  Paris  (Revue  d*  Hygiene  et  de  Pol  ire  sanitaire,  December, 
1890 ;  Annual  Universal  Medical  Scu  na  s,  1 892),  expresses  the  opinion  that 
in  nearly  all  instances  diphtheria  is  propagated  by  infected  clothing  or 
furniture.  He  states  that  in  a  diphtheritic  ward  in  Paris,  among  1,741 
admitted  were  153  that  did  not  have  diphtheria  at  the  time,  yet  none  of 
them  contracted  it.  The  means  of  prophylaxis  employed  in  this  ward 
were:  a  metallic  screen  about  the  bed;  disinfection  of  articles  used  by 
the  patient  by  boiling  in  about  a  six  per  cent  solution  of  sodium  carbon- 
ate; disinfection  of  the  bedding  and  clothing  by  heat,  and  of  the  walls 
and  furniture  by  washing  with  a  solution  of  mercury  bichloride.  At- 
tendants and  doctors  wear  blouses  that  are  disinfected  by  heat  daily  and 
wash  themselves  in  a  bichloride  solution  or  in  a  five  per  cent  solution  of 
carbolic  acid. 

Ice  taken  frequently  in  the  mouth  tends  to  relieve  thirst  and  reduce 
congestion.  When  children  will  not  take  this,  Lennox  Browne  (Diseases 
of  the  Throat,  2d  ed.)  recommends  the  use  of  frozen  milk  or  frozen 
beef  tea.  Of  nutritious  drinks,  milk  is  the  most  important;  beef  tea 
and  the  various  broths  may  be  given  in  addition  when  the  child  will 


DIPHTHERIA.  335 

take  them,  and  these  may  be  supplemented  by  rice  water  or  barley  water ; 
the  latter  is  sometimes  taken  more  readily  if  flavored  with  lemon  juice. 
As  soon  as  the  appetite  becomes  impaired,  these  liquid  nutrients  must 
be  given  at  regular  intervals,  and  in  as  great  a  quantity  as  the  patient 
can  be  induced  to  take.  To  a  child  ten  years  of  age  as  much  as  half  a 
pint  of  milk  or  its  equivalent  should  if  possible  be  given,  every  third 
hour  night  and  day.  Sometimes  with  children  it  is  necessary  to  with- 
hold water  in  order  that  they  may  take  the  liquid  nourishment. 

Fontaine,  acting  on  the  principle  that  germs  cannot  exist  in  acid 
solutions,  recommends  frequent  drinks  or  gargles  acidulated  with  citric 
acid.  On  the  same  principle,  pineapple  juice  has  lately  been  highly  rec- 
ommended, particularly  by  the  laity.  When  patients  cannot  take  food,  • 
or  when  it  will  not  be  retained  by  the  stomach,  nutritive  enemata  become 
necessary;  in  this  case  the  various  preparations  of  peptonized  meat  are 
exceedingly  useful. 

Alcoholic  stimulation  is  of  great  importance,  and  is  usually  recom- 
mended early  in  the  attack,  but  I  doubt  its  value  at  this  time.  The  form 
in  which  it  is  administered  is  of  little  importance,  so  long  as  it  is  accept- 
able to  the  patient;  whisky  or  brandy  is  most  commonly  used,  but 
children  will  generally  take  much  more  readily  alcohol  diluted  with  two 
parts  of  syrup  of  tolu,  given  in  as  much  water  as  desired. 

The  early  continued  application  of  cold  externally  is  often  of  the 
greatest  service;  for  this  purpose  the  throat  may  be  fitted  with  a  coil  of 
rubber  or  metallic  tubing  through  which  a  current  of  ice  water  is  kept 
constantly  passing,  or  the  ioe  bag  may  be  used.  When  the  latter  is  em- 
ployed, the  ice  should  be  broken  into  small  pieces  and  changed  about 
once  an  hour;  the  bag  should  not  be  more  than  half  filled,  so  that  it 
may  be  accurately  applied  to  the  surface.  When  the  false  membrane 
begins  to  separate,  hot  applications  have  seemed  more  beneficial  than 
cold,  and  occasionally,  even  in  the  early  part  of  the  attack,  the  patient  so 
seriously  objects  to  the  cold  that  hot  applications  may  be  used  instead, 
the  effect  being  much  the  same  providing  the  application  is  continuous 
and  as  hot  as  can  be  home. 

Topical  Treatment. — A  variety  of  substances  have  been  used  with  the 
hope  of  removing  'the  false  membrane.  The  simplest  of  these  is  steam, 
applied  either  with  the  croup  tent  or  the  steam  atomizer.  This  may  be  im- 
pregnated with  the  time  honored  lime  water,  or  with  various  other  sub- 
stances according  to  the  fancy  of  the  physician.  There  can  be  no  doubt 
that  lime  water  is  cajDable  of  dissolving  the  false  membrane  when  the 
latter  is  immersed  in  it  for  a  sufficient  length  of  time,  but  probably  it 
has  very  little  influence  upon  the  membrane  in  the  throat.  Liquor 
potassa,  one  part  to  four  of  water,  may  be  used  with  equally  good  results. 
Mackenzie  (Diseases  of  the  Throat  and  Nose)  highly  recommended 
lactic  acid  applied  freely  with  a  brush  or  pledget  of  lint.  He  did  not 
so  state,  but  left  us  to  infer  that  it  was  applied  in  full  strength.     He 


336  DISEASES  OF  THE  FAUCES 

classed  it  as  among  the  most  reliable  solvents  of  diphtheritic  membrane. 
Lennox  Browne  recommends  a  solution  of  lactic  acid  to  be  applied  every 
two  or  three  hours  by  the  nurse  in  from  one  to  six  parts  of  water,  and 
to  be  used  pure  once  or  twice  a  day  by  the  surgeon.  Trypsin,  papain, 
and  resorcin  have  all  been  recommended  for  their  supposed  solvent  effects. 
Tannic  acid,  alum,  and  sulphur  have  been  used  in  the  form  of  powder  by 
many  physicians,  but  are  of  doubtful  utility.  Various  local  antiseptic 
applications  are  useful  when  they  can  be  made  without  too  much  objec- 
tion by  the  patient;  but  I  believe  that  whatever  is  used  should  be  so  mild 
as  to  cause  but  little  pain,  otherwise  it  is  apt  to  do  more  harm  than  good. 
Of  these,  mercury  bichloride,  carbolic  acid,  potassium  permanganate, 
sodium  chlorate,  glveerole  of  borax,  chloral,  and  the  tincture  of  iron  are 
most  efficient.  The  first  is  used  in  the  proportion  of  1  to  4,000  of  water, 
or  even  as  strong  as  1  to  1,000,  but  this  is  too  strong  for  ordinary 
use.  Carbolic  acid  is  used  in  the  strength  of  from  one  to  five  per 
cent;  the  latter  is  especially  recommended  by  Oertel  (Ziemssen's  Cyclo- 
pedia, English  translation.  Vol.  II.).  Potassium  permanganate  may  be 
used  in  the  strength  of  gr.  v.  ad  \  i.,  the  liquor  soda>  chlorata?  four 
drachms  to  ten  ounces,  or  potassium  chlorate  a  saturated  solution. 
Hugh  Hemming,  of  Kimbolton,  England,  advocates  the  syrup  of 
chloral,  gr.  xxv.  ad  3i.,  applied  everyone  or  two  hours.  Sulphurous 
acid  properly  diluted  is  also  beneficial.  Hydrogen  peroxide  has  been 
highly  recommended  as  a  spray  either  in  its  full  strength  (Marchand's) 
as  obtained  from  the  druggist,  or  diluted  according  to  the  degree  of 
smarting  produced.  Pure  alcohol  is  used  by  some  as  a  gargle  or  spray, 
with  apparent  advantage.  Tincture  of  myrrh  has  also  been  extolled  as  a 
local  application.  Tincture  of  the  chloride  of  iron  may  be  used  either 
in  the  form  of  a  spray  or  by  means  of  a  swab. 

G.  Y.  Black,  of  Jacksonville,  111.  {Dent id  Review,  March  15th,  1S89,  p. 
128),  has  shown  that  the  officinal  cinnamon  water,  although  harmless  to 
the  patient,  is  one  of  the  most  efficacious  antiseptics;  and  Koux  and  Yersin 
{Annates  de  Gynecologie  et  d' Obstetrique,  September,  1889;  Paris) 
have  demonstrated  that  the  toxicity  of  cultures  of  diphtheritic  bacilli 
is  greatly  diminished  by  the  addition  of  carbolic  acid,  borax,  or  boric 
acid;  I  have,  therefore,  been  induced  to  try  as  a  local  application  a  sat- 
urated solution  of  boric  acid  in  cinnamon  water.  This  is  neither  pain- 
ful, unpleasant,  nor  dangerous,  and  has  seemed  to  me  more  efficient 
than  other  local  remedies  which  I  have  employed.  Any  of  these  appli- 
cations may  be  of  more  or  less  value  when  the  patient  does  not  rebel 
against  their  use;  if  a  contest  becomes  necessary  every  time  the 
remedy  is  applied,  it  will  probably  do  more  harm  than  good.  The  tinc- 
ture of  iron,  when  administered  internally  frequently  and  in  compara- 
tively large  doses  as  recommended  below,  has  all  of  the  local  influence 
that  is  usually  necessary,  and  obviates  the  necessity  of  sprays  or  gargles. 

When  the  diphtheritic  process  extends  to  the  nose,  the  nares  should  be 


DIPHTHERIA.  337 

washed  three  or  four  times  daily  with  a  saturated  solution  of  boric  acid 
or  some  mild  alkaline  wash,  which  should  always  be  used  warm.  The 
washing  may  often  be  accomplished  by  an  atomizer.  Whenever  it  is 
necessary  to  employ  a  syringe,  the  patient  should  be  placed  face  down- 
ward so  that  the  fluid  will  not  run  into  the  throat  and  cause  strangling. 
After  the  washing,  a  powder  consisting  of  iodol,  sugar  of  milk,  and  pa- 
pain— equal  parts,  may  be  freely  blown  into  the  nose. 

Internal  Treatment. — Physicians  generally  are  agreed  that  the  treat- 
ment of  diphtheria  should  be  supporting  and  stimulating  from  the  be- 
ginning. With  this  in  view,  iron,  quinine,  strychnine,  and  alcoholic  stim- 
ulants have  been  employed  for  generations,  and  they  still  hold  the  first 
place  with  a  majority  of  the  profession.  No  infernal  remedy  has  seemed 
to  be  more  effective  than  tincture  of  the  chloride  of  iron  given  in  fre- 
quent and  comparatively  large  doses,  amounting  to  about  one  minim  of 
the  medicine  for  each  year  of  the  child's  age  administered  every  one  or 
two  hours,  according  to  the  severity  of  the  case.  I  usually  combine  it 
with  a  small  quantity  of  glycerin  and  sufficient  syrup  of  tolu  to  make 
one  drachm,  and  direct  the  patient  to  take  it  without  dilution,  provid- 
ing it  does  not  cause  smarting.  As  the  throat  becomes  more  sensitive, 
the  remedy  is  diluted  sufficiently  to  avoid  much  discomfort.  To  pre- 
vent any  irritation  of  the  stomach,  it  is  well  for  the  patient  to  take  a 
drink  of  water  before  the  medicine  is  given,  and  as  much  more  as  desired 
five  minutes  afterward.  Quinine  may  be  given  at  the  same  time,  prefer- 
ably in  pills  or  capsules ;  otherwise  the  patient  may  become  so  disgusted 
as  to  refuse  it  altogether.  Alcoholic  stimulants  should  be  given  freely 
when  the  pulse  becomes  weak  and  the  vitality  diminished.  If  there 
is  a  tendency  to  heart  failure,  no  remedy  is  of  greater  value  than  nux 
vomica  in  some  form.  Strychnine  may  be  given,  but  the  tincture  of 
nux  vomica  has  seemed  to  me  more  effectual,  and  it  should  be  given 
in  comparatively  large  doses,  sometimes  as  much  as  half  a  minim  for 
each  year  of  the  child's  age,  being  required  every  one  or  two  hours. 
Within  the  past  few  years  mercury  bichloride  has  been  largely  used  in 
the  treatment  of  this  disease  with  apparent  success,  and  other  prepara- 
tions of  mercury  are  recommended  by  various  authors.  Pilocarpine  is 
advised  by  Oertel,  who  believes  that  it  hastens  separation  of  the  mem- 
brane but  its  depressing  effect  upon  the  heart  is  a  serious  objection  to  its 
use.  Among  other  remedies  which  have  received  the  sanction  of  good 
authority  are  cubebs,  copaiba,  potassium  chlorate,  the  sulpho-carbolates, 
sodium  and  potassium  sulphites,  salicylic  acid,  the  salicylates,  and  potas- 
sium, sodium  and  ammonium  benzoates.  Indeed,  there  are  few  remedies 
of  any  potency  in  any  disease  that  have  not  been  tried  for  this  affec- 
tion, and  which  have  not,  for  a  time  at  least,  received  unmerited  praise. 

When  the  disease  extends  to  the  larynx,  remedies  calculated  to  re- 
move the  membrane  or  to  prevent  spasm  of  the  muscles  have  been  rec- 
ommended.    For  this   purpose  emetics   are   chiefly  employed;   among 


338  DISEASES  OF  THE  FAUCES. 

those  in  common  use  are  alum,  ipecacuanha,  tartar  emetic,  zinc  sulphate, 
copper  sulphate,  apomorphine,  and  turpeth  mineral.  Of  these,  ipecacu- 
anha and  alum  are  the  simplest  and  safest,  though  the  turpeth  mineral 
is  largely  employed,  and  copper  sulphate  is  highly  recommended  by  good 
authorities.  These,  however,  should  only  be  employed  early  in  the  attack. 
I  fully  indorse  the  ancient  belief  that  in  this  condition  mercurials  have 
considerable  power  in  preventing  the  dejsosit  of  membrane,  and  remov- 
ing that  which  has  already  been  formed.  I  prefer  the  mild  chloride  of 
mercury,  administered  in  doses  of  about  half  a  grain  for  each  year  of  the 
child's  age,  every  one  or  two  hours  until  it  acts  upon  the  bowels.  The 
frequency  of  the  dose  is  then  gradually  diminished,  and,  as  soon  as 
dyspnoea  has  been  relieved,  the  drug  is  withdrawn.  It  is  surprising 
how  slight  its  effects  are  upon  the  bowels  in  this  condition;  a  child 
two  years  of  age  will  frequently  take  twenty  to  forty  grains  of  calomel 
without  serious  disturbance  of  the  bowels.  I  have  never  seen  any 
ill  effects  from  its  use  in  this  way,  and  I  believe  it  can  do  no  harm. 
As  obstruction  of  the  glottis  increases,  the  lips  and  finger  nails  be- 
come blue,  there  is  recession  of  the  softer  portion  of  the  chest  walls 
during  inspiration,  with  labored  and  stertorous  respiration,  and  other 
signs  of  approaching  suffocation.  At  this  time  operative  measures 
should  not  be  delayed.  The  operation  to  be  preferred  depends  some- 
what upon  the  age  of  the  child  and  its  surroundings.  Other  things 
being  equal,  in  children  under  five  years  of  age,  I  decidedly  prefer  in- 
tubation by  O'Dwyer's  method.  In  older  children,  intubation  is  not  quite 
as  satisfactory  as  tracheotomy,  still  it  has  been  found  useful  in  many 
cases,  particularly  where  the  graver  operation  will  not  be  permitted; 
therefore  I  would  advise  that  it  be  tried  first;  it  does  not  preclude  the 
subsequent  performance  of  tracheotomy.  These  operations  are  described 
under  the  treatment  of  membranous  croup. 


CHAPTER   XX. 

DISEASES   OF   THE   FAUCES.— Continued. 

ACUTE   FOLLICULAR  PHARYNGITIS. 

Acute  follicular  pharyngitis  is  an  acute  inflammation  of  the  follicles 
in  the  mucous  membrane  of  the  pharynx,  occurring  most  frequently  in 
cold  and  damp  climates,  and  in  young  or  middle-aged  people.  Those 
suffering  from  a  rheumatic  diathesis  are  peculiarly  prone  to  it. 

Anatomical  and  Pathological  Chakacteristics. — As  a  result 
of  the  inflammation,  the  mucous  follicles  become  closed  and  finally  dis- 
tended by  their  altered  secretions,  in  some  cases  the  distention  becom- 
ing so  great  that  the  follicle  is  ruptured  and  a  small  ulcer  results. 

Etiology. — The  most  frequent  causes  are:  exposure  to  inclemency 
of  the  weather;  the  abuse  of  tobacco;  and  excessive  use  of  the  voice  in 
badly  ventilated  rooms  or  out  of  doors,  especially  in  the  night  air.  The 
inhalation  of  irritating  particles  of  dust  or  of  smoke  is  an  occasional 
cause. 

Symptomatology. — Mild  cases  begin  with  malaise,  which  may  last 
for  a  few  days,  the  patient  complaining  in  the  mean  time  of  some  little 
fever  and  more  or  less  discomfort  in  the  throat.  Early  in  the  attack,  the 
patient  usually  experiences  dryness,  smarting,  or  pricking  sensations.  In 
severe  cases  pain  and  swelling  are  excessive  and  the  constitutional  symp- 
toms very  pronounced,  the  fever  running  up  several  degrees.  There  is 
often  a  slight  hacking  cough,  with  expectoration  of  a  small  amount  of 
glairy,  tenacious  mucus.  Hoarseness  is  present  in  most  instances,  due 
to  extension  of  the  inflammation  to  the  larynx.  Upon  examination  of 
the  throat,  the  mucous  membrane  is  found  congested;  and  in  patches, 
corresponding  to  the  follicles,  there  is  swelling  and  deeper  congestion. 
Several  of  these  swollen  follicles  may  be  visible,  especially  just  back  of 
the  posterior  pillars  of  the  fauces.  Some  are  round,  others  oval,  and 
all  more  or  less  elevated  above  the  surface.  Some  with  yellowish  sum- 
mits look  like  pustules.  At  other  points  where  rupture  of  the  follicles 
and  escape  of  their  contents  has  occurred,  small  ulcers  are  visible,  and 
remain  for  a  few  days.  Where  the  contents  of  a  follicle  are  retained  for 
a  number  of  days,  they  become  somewhat  cheesy. 

Diagnosis. — Acute  follicular  pharyngitis  is  apt  to  be  mistaken  for 
simple  acute  sore  throat.  The  essential  points  in  the  differential  diag- 
nosis are  the  round  or  oval  follicles  more  or  less  elevated  above  the  sur- 
face, accompanied  by  pustules  or  small  ulcers. 


340  DISEASES   OF  THE  FAUCES. 

Prognosis. — The  disease  usually  terminates  in  resolution  within  a 
few  days.  In  most  cases,  however,  there  is  a  tendency  to  recurrence,  and 
the  attack  may  be  repeated  many  times.  I  have  seen  one  patient  who 
has  had  an  attack  every  three  or  four  weeks  during  the  last  two  years. 
Nearly  always  there  is  some  disease  of  the  nasal  passages  or  of  the  naso- 
pharynx associated  with  this  predisjDosition  to  acute  follicular  pharyn- 
gitis. 

Treatment. — In  cases  where  the  portal  circulation  is  sluggish,  the 
administration  of  salines  and  an  occasional  mercurial  cathartic  will  work 
much  benefit.  In  lieu  of  mercurials,  the  mineral  acids,  especially  hydro- 
chloric, will  be  found  useful  as  hepatic  stimulants.  Many  of  these  patients 
are  troubled  with  poor  digestion,  which  may  be  best  relieved  by  the 
use  of  bitter  tonics.  Quinine  is  useful,  more  especially  in  ultra-malarial 
districts,  but  under  ordinary  conditions  I  have  found  hydrastine  muriate 
and  extract  of  nux  vomica  more  efficient;  but  whatever  bitter  tonics  are 
prescribed,  the  doses  should  be  small.  The  local  treatment,  which  has 
the  prestige  of  antiquity,  consists  of  the  application  of  solutions  of  silver 
nitrate  in  strength  of  from  gr.  xxx.  to  cxx.  ad  3  i.  It  should  be  made 
with  an  absorbent-cotton  swab  or  large  brush,  saturated  with  the  solu- 
tion, but  not  so  wet  that  drops  fall  from  it.  The  tongue  should  be  de- 
pressed as  far  as  possible,  and  the  application  made  quickly  from  the 
lower  part  of  the  pharynx  upward,  by  which  procedure  the  whole 
pharynx  can  be  treated  at  once.  Applications  of  silver  nitrate  often 
cause  strangling,  even  if  apjdied  only  to  the  pharynx;  they  taste  badly 
and  cause  prolonged  smarting  if  used  in  strength  sufficient  to  be  of 
value.  For  these  reasons  I  seldom  emjfioy  this  remedy,  and  I  have  an 
impression  that  it  is  of  no  more  therapeutic  value  than  less  disagreeable 
agents.  In  these  cases  the  astringent  and  sedative  spray  containing 
morphine,  carbolic  acid  and  tannic  acid  (Form.  93)  has  not  been  disap- 
pointing. In  obstinate  cases  some  authors  recommend  the  actual 
cautery,  in  the  form  of  a  small  wire  with  a  little  bulbous  end,  which  is 
heated  and  touched  to  the  inflamed  follicles.  This  results  in  a  more 
acute  inflammation  for  a  short  time,  followed  by  thorough  resolution. 
The  galvano-cautery  is  much  more  easily  applied  than  the  actual  cautery, 
and  is  to  be  recommended  when  needed.  In  cauterizing,  not  more  than 
two  or  at  most  three  small  spots  should  be  touched  at  a  time,  otherwise 
too  much  inflammation  will  be  caused.  The  cautery  is  not  often  needed 
in  acute  cases. 

CHRONIC   FOLLICULAR  PHARYNGITIS. 

Synonyms. — Granular  sore  throat,  clergyman's  sore  throat,  chronic 
pharyngitis,  sometimes  kno»vn  as  hospital  sore  throat. 

The  disease  is  a  chronic  inflammation  of  the  pharyngeal  mucous 
membrane,  the  brunt  of  which  is  expended  upon  the  follicles.     It  is 


CHRONIC  FOLLICULAR  PHARYNGITIS.  341 

characterized  by  hypertrophy  of  the  mucous  membrane  and  irregular 
plastic  exudation  upon  it,  occurring  in  patches,  especially  about  the  fol- 
licles. It  is  most  marked  in  damp  and  chilly  climates,  occurs  most 
often  in  those  of  delicate  constitution,  and  is  perhaps  the  most  frequent 
of  all  chronic  affections  of  the  fauces  or  throat.  Three  varieties  of  the 
disease  have  been  described:  the  hypertrophic,  the  most  common;  the 
atrophic,  not  very  frequent;  and  the  exudative,  which  is  rare.  Lennox 
Browne  does  not  recognize  an  exudative  form,  but  I  have  seen  several 
well  marked  cases. 

Anatomical  and  Pathological  Characteristics. — In  the  hyper- 
trophic variety  the  mucous  membrane  of  the  pharynx  is  studded  with 
swollen  follicles  varying  from  two  or  three  to  ten  or  twelve  in  number. 
These  are  red  or  yellowish  red  in  color,  oval  or  round  in  shape  and  ele- 
vated one  to  three  millimetres  above  the  surrounding  surface.  Those  of 
a  yellowish  red  color  sometimes  appear  like  small  blisters,  with  gelati- 
nous contents.  Often  two  or  three  of  these  follicles  are  grouped  closely 
together  or  united;  this  is  much  more  frequent  at  the  angles  of  the 
pharynx  just  back  of  the  posterior  pillars,  where  they  often  form  long 
red  welts.  One  or  more  of  the  superficial  veins  are  usually  enlarged, 
sometimes  to  a  diameter  of  one  or  two  millimetres,  and  they  occasionally 
seem  to  terminate  in  the  enlarged  follicles.  Where  the  inflammation 
has  existed  for  a  long  time,  it  finally  results  in  more  or  less  atrophy. 
Some  of  the  enlarged  follicles  may  remain,  but  the  mucous  membrane 
between  them  looks  thin  and  whitish  and  sometimes  seems  to  be  covered 
with  muco-pus;  an  appearance  due  to  the  atrophied  whitened  tissue 
shining  through  the  secretions.  In  the  hypertrophic  form,  the  bulk  of 
the  enlarged  follicles  has  been  found  microscopically  to  be  made  up  of 
swollen  epithelial  cells.  In  the  exudative  form,  yellowish  spots  will  be 
seen  at  the  mouths  of  some  of  the  follicles,  similar  to  the  yellow  spots 
seen  in  chronic  follicular  tonsillitis,  due  to  cheesy  secretions  from  these 
diseased  glands,  mingled  with  viscid  mucus. 

Etiology. — The  disease  may  be  caused  by  the  constant  inhalation 
of  vitiated  atmosphere,  by  frequent  exposures  to  cold  or  damp,  and  by  the 
use  of  tobacco — particularly,  there  is  reason  to  believe,  by  excessive  smok- 
ing. Occasionally  it  seems  to  have  been  caused  by  the  inhalation  of 
acrid  fumes,  as  for  example,  those  to  which  tinsmiths  are  exposed.  Over- 
use of  the  voice,  particularly  in  badly  ventilated  rooms  or  in  the  open 
air,  is  evidently  a  frequent  cause.  The  ingestion  of  spices  is  possibly  an 
occasional  cause  of  the  disease.  It  has  been  attributed  also  to  digestive 
disturbances,  with  which  it  is  frequently  associated.  The  most  common 
cause  is  obstruction  of  the  nasal  passages  by  swelling  of  the  turbinated 
bodies,  polypi,  and  deflection  or  exostosis  cf  the  septum.  As  a  result  of  such 
obstruction,  normal  nasal  respiration  gives  place  to  mouth-breathing, 
which  by  rarefaction  of  air  in  the  naoO-pbarynx  with  each  inspiration, 
finally  causes  congestion  of  the  throat,  and  if  prolonged  terminates  in 


34*2  DISEASES   OF  THE  FAUCES. 

disease  of  its  mucous  membrane.  That  the  affection  is  hereditary  in 
some  instances  there  can  he  no  doubt.  It  is  claimed  that  the  arthritic, 
rheumatic,  and  scrofulous  diatheses  favor  the  production  of  this  disease. 
The  frequent  recurrence  of  acute  attacks  is  apparently  the  cause  in  some 
instances.  Chronic  follicular  pharyngitis  is  sometimes  found  following 
one  of  the  eruptive  diseases.  It  is  favored  by  chronic  alcoholism,  and 
exposure  to  prolonged  dry  heat  is  a  not  very  uncommon  cause.  Mental 
depression,  portal  congestion,  and  torpor  of  the  liver  may  be  put  down 
as  among  the  rare  causes. 

Symptomatology. — Usually  there  is  at  first  passive  congestion,  which 
may  run  into  the  chronic  condition  of  inflammation  without  greatly  at- 
tracting the  patient's  attention.  The  first  complaint  is  liable  to  be  of 
slight  discomfort  in  the  throat,  which  may  be  a  feeling  of  simple  dryness, 
or  some  peculiar  sensation,  or  may  amount  to  actual  pain.  Patients  usually 
speak  of  dryness  or  pricking  sensations  in  the  fauces,  sometimes  of  a 
hair,  or  lump,  or  burning  pain,  which  may  be  continuous  or  only  occur 
at  periods  during  the  day.  Pronounced  instances  of  this  character  are 
more  prone  to  occur  in  the  exudative  variety  of  the  disease.  Partial 
deafness  sometimes  occurs,  and  it  may  even  become  complete.  This  is 
due  to  an  extension  of  the  inflammatory  process  into  and  along  the 
Eustachian  tubes.  The  giving  way  of  the  voice  is  usually,  however,  the 
first  thing  which  admonishes  the  patient  to  seek  medical  advice.  When 
the  voice  is  used  more  or  less  continuously  for  half  or  three-quarters  of 
an  hour,  the  person  becomes  fatigued,  and  the  enunciation  is  likely  to 
fail.  Although  hoarseness  is  not  a  constant  feature,  yet  nearly  all  pa- 
tients are  troubled  with  it  to  a  greater  or  less  extent  upon  slight  expo- 
sure or  free  use  of  the  voice.  Short  of  hoarseness,  the  expression  of  the 
voice  will  be  found  feeble  or  muffled,  and  the  singing  voice  is  generally 
lost.  A  few  patients  may  even  suffer  from  complete  aphonia  as  a  result 
of  the  extension  of  the  disease  to  the  larynx.  All  the  symptoms  are 
variable,  and  are  apt  to  change  in  the  same  patient;  the}*  are  gener- 
ally intensified  during  the  cold  and  changeable  seasons,  while  an  im- 
provement occurs  in  the  summer.  In  nearly  all  cases,  careful  investi- 
gation will  lead  to  the  discovery  that  there  is  oral  respiration.  Many 
patients,  who  affirm  that  they  breathe  perfectly,  will  be  found  to  breathe 
with  the  mouth  open,  particularly  during  the  latter  portion  of  the  night. 
The  constitutional  effects  of  follicular  pharyngitis  depend  upon  the  im- 
peded nasal  respiration,  or  upon  the  digestive  disturbances  which  may 
be  a  causative  factor  of  the  disease.  The  frequent  hawking  attempt  to 
clear  the  throat  is  often  one  of  the  most  noticeable  symptoms  of  this 
affection,  and  is  due  to  the  uncomfortable  sensation  produced  by  the 
tenacious  mucus  adhering  to  the  palate  or  pharynx.  In  a  few  cases  there 
is  severe  cough,  particularly  in  the  morning,  and  mucous  pellets  are 
expectorated  early  in  the  day,  more  especially  when  the  disease  has  ex- 
tended to  the  larynx.  In  some  cases  there  is  muco-purulent  expectora- 
tion, and  occasionally  the  sputum  is  streaked  with  blood;  this,  however, 


CHRONIC  FOLLICULAR  PHARYNGITIS. 


343 


is  of  no  consequence  in  the  diagnosis  or  prognosis,  though  it  is  often 
alarming  to  the  patient.  In  many  cases  the  secretions  which  form  in 
the  naso-pharynx  and  nose  gradually  find  their  way  downward  and  back- 
ward into  the  pharynx,  or  even  into  the  larynx,  and  may  be  seen  adher- 
ing to  the  posterior  pharyngeal  wall  as  thick,  dry  or  moist  scabs,  or  they 
may  hang  in  stringy  masses  from  the  edge  of  the  palate.  There  will 
usually  be  found  a  considerable  amount  of  mucus  in  the  naso-pharynx, 
and  some  adhering  to  the  mucous  membrane  of  the  larynx,  where  it  may 
cause  cough.  Commonly  there  is  a  coated  tongue,  together  with  other 
evidences  of  digestive  derangement.  Where  pain  is  experienced,  it  may 
be  during  the  act  of  swallowing,  but  in  some  cases  the  discomfort  may 
be  relieved  by  deglutition,  and  not  reap- 
pear  until  an  hour  or  so  after  eating. 
Liquids  are  easily  swallowed  by  some  pa- 
tients, but  solids  cause  pain;  with  others 
the  opposite  is  true;  while  to  still  others 
neither  will  cause  any  discomfort.  Upon 
examination  of  the  throat,  the  surface 
(Fig.  89)  will  be  found  congested  and  swol- 
len in  patches,  the  blood  vessels  in  many 
cases  enlarged,  and  the  follicles  of  abnor- 
mal development.  About  the  latter  there 
is  usually  a  narrow  zone  of  congestion.  At 
the  base  of  the  tongue  diseased  follicles 
similar  to  those  upon  the  pharyngeal  wall 
may  be  observed.  In  the  exudative  type 
of  the  affection,  two  or  three  yellowish 
points  similar  to  those  of  chronic  follicular  tonsillitis  may  be  seen 
at  some  part  of  the  pharynx.  Small  ulcers  are  described  by  Cohen 
and  others  as  being  present  occasionally,  though  I  have  never  seen 
them.  The  tonsils  are  often  involved,  in  either  chronic  follicular 
inflammation  or  simple  hypertrophy.  The  palate  may  be  relaxed  and 
the  uvula  elongated ;  and  the  larynx  is  not  infrequently  the  seat  of  more 
or  less  congestion,  more  particularly  the  posterior  ends  of  the  vocal 
cords,  especially  after  using  the  voice.  Examination  of  the  naso-pharynx 
will  reveal  congestion  of  its  mucous  membrane,  with,  generally,  abundant 
secretion.  Often  there  is  submucous  thickening  at  the  sides  of  the 
vomer,  which  may  appear  grayish  white  and  slightly  nodular,  and  is 
sometimes  sufficiently  large  to  almost  occlude  the  posterior  nares.  Such 
obstruction  may  also  result  from  hypertrophy  of  the  posterior  ends  of 
the  turbinated  bodies.  When  the  secretion  is  scanty  and  the  mucous 
membrane  dry  and  thin,white  atrophied  tissue  is  seen  between  the  follicles 
— a  condition  known  as  pharyngitis  sicca,  or  atropine  follicular  pharyn- 
gitis. Sometimes  the  entire  pharyngeal  wall  will  be  found  covered  with 
dried  secretions. 


Fig.  89.— Chronic  Follicular. 
Pharyngitis  (Cohen). 


344  DISEASES   OF  THE  FAUCES. 

Diagnosis. — Syphilis  is  the  only  disease  with  which  the  affection  is 
likely  to  be  confounded.  When  there  is  simple  congestion,  with  very 
slight  enlargement  of  the  follicles,  it  may  be  difficult  or  impossible  to 
distinguish  it  from  some  cases  of  syphilitic  sore  throat,  but  in  the  latter 
there  are  usually  either  the  mucous  patches  of  the  secondary  stage  or 
the  ulcers  or  scars  of  the  tertiary  period,  the  presence  of  which  renders 
the  diagnosis  plain.  The  remote  possibility  of  mistaking  the  ulcer  of 
chronic  follicular  pharyngitis — which  is  very  rare — for  that  of  syphilis 
may  be  remembered.  Chronic  follicular  pharyngitis  may  possibly  be 
confounded  with  tuberculin-  sore  threat,  but  in  this  the  ulcers  are  super- 
ficial and  irregular,  and  the  edges  not  distinctly  marked ;  whereas  in 
chronic  follicular  pharyngitis  they  occur,  if  at  all,  but  rarely,  and  then 
only  as  small,  round  ulcers  where  distended  follicles  have  ruptured. 
The  presence  or  absence  of  the  constitutional  evidences  of  tuberculosis 
will  have  great  weight  in  determining  the  true  nature  of  the  disease. 

Prognosis. — Chronic  follicular  pharyngitis  may  continue  for  years 
unless  efficiently  treated.  In  many  cases  the  inflammation  gradually 
extends  to  the  ear,  or  to  the  larynx,  giving  rise  to  deafness,  or  to  loss  of 
voice.  Again,  the  hypertrophic  form  of  the  disease  may  terminate  in 
the  atrophic,  which  is  far  more  troublesome  to  the  patient  and  very  diffi- 
cult to  cure.  The  exudative  form  of  the  affection  is  generally  more  ob- 
stinate. 

Treatment. — The  old  adage  that  an  ounce  of  prevention  is  worth 
a  pound  of  cure  could  well  be  applied  in  this  disease,  were  it  not  that 
the  opportunity  is  generally  lacking  to  the  physician,  inasmuch  as  the 
patient  does  not  present  himself  soon  enough.  A  caution  should  be 
given,  however,  regarding  those  exposures  already  mentioned  which  are 
known  to  exert  a  damaging  influence  upon  the  parts,  for  they  not  only 
cause  the  disease,  but  favor  its  continuation.  Faulty  digestion  and  elim- 
ination should  be  corrected.  In  many  cases  a  course  of  diuretics  and 
bitter  tonics  is  indicated.  Arsenious  acid  is  often  of  special  service.  Those 
predisposed  to  rheumatism  must  have  appropriate  constitutional  treat- 
ment. Locally,  silver  nitrate  is  an  old  time  remedy,  but  one  which  I 
rarely  recommend.  It  may  be  applied  in  strong  solution  or  in  the  solid 
stick,  but,  if  the  latter,  only  a  small  area  should  be  treated  at  one  sitting. 
I  have  had  excellent  results  from  powdered  hydrastine  (Form.  17-4)  by  in- 
sufflation into  the  naso-pharynx  in  cases  presenting  several  enlarged  folli- 
cles of  a  deep  pink  color,  providing  the  surrounding  mucous  membrane 
is  moist,  and  the  secretion — except  in  the  naso-pharynx — is  not  excessive. 
The  powder  remains  in  the  nasopharynx  several  hours,  gradually  work- 
ing down  the  pharynx  and  thereby  prolonging  the  effect.  At  first  only 
a  small  quantity  should  be  used,  in  order  to  ascertain  the  susceptibility 
of  the  patient,  since  in  some  cases  the  remedy  applied  in  this  way  causes 
severe  pain.     Ordinarily  it  produces  no  discomfort. 

In  mild  cases,  and  often  in   those   more  severe,  local   astringents  are 


CHRONIC  FOLLICULAR  PHARYNGITIS. 


345 


desirable,  and  troches  of  krameria,  either  simple  or  compound  (Form.  38 
and  -il),  will  be  most  conveniently  used  by  the  patient.  Sprays  to  the 
oro-pharynx  of  copper  sulphate  in  solution  of  ten. or  twenty  grains  ad  3  i., 
zinc  chloride  or  zinc  sulphate  in  the  same  proportion,  or  mercury  bichlo- 
ride gr.  ss.  ad  3  i.  are  also  useful,  Somewhat  weaker  solutions  of  the  same 
may  be  used  for  the  naso-pharynx,  which  in  nearly  all  instances  requires 
treatment;    indeed,  it  is  often  more  important  to  medicate  the  naso- 


Fig.  90.— Ingals'  Modification  of  Shuhly's  Battery.  This  has  two  large  cells.  The  ele- 
ments consist  of  large  zinc  and  carbon  plates,  which  may  be  depressed  to  any  desired  depth  by  the 
screw  shown  in  the  centre.  Thus  the  current  may  be  accurately  regulated.  The  cautery  battery 
here  shown.  I  have  used  for  years  with  much  satisfaction,  though  for  the  past  two  years  I  have  more 
commonly  employed  a  storage  battery  so  connected  that  I  can  easily  charge  it  from  the  Edison 
current.  It  is  somewhat  more  convenient,  when  working  well,  than  the  battery  here  shown,  but 
more  expensive  and  less  reliable. 


pharynx  than  the  other  parts.  When  the  follicles  are  much  enlarged, 
the  above  treatment  will  not  be  sufficient,  and  there  will  be  no  great  relief 
until  they  are  cured.  To  accomplish  this,  they  may  be  cauterized  with 
nitric  acid,  chromic  acid,  or  London  paste,  a  small  quantity  being  applied 
directly  to  the  surface  of  the  follicle,  not  to  the  surrounding  membrane; 
only  two  or  three  of  the  follicles  should  be  treated  at  each  sitting.  This 
procedure  may  be  repeated  every  four  or  five  days  until  all  are  removed. 
Sometimes  it  is  well  to  split  the  follicle  with  a  sharp  knife,  and  then 
crowd   into  the   incision  the   pointed   end  of  a  stick  of  silver  nitrate. 


346  DISEASES  OF  THE  FAUCES. 

Some  are  in  favor  of  scraping  off  these  follicles  with  a  curette.  The 
actual  cautery  may  be  employed — as  recommended  for  acute  follicular 
pharyngitis— but  the  galvano-cautery  (Figs.  90  and  91)  is  the  best  means 
for  getting  rid  of  the  hypertrophied  follicles.  In  using  it  the  electrode 
is  applied  cold,  the  current  is  then  turned  on  for  a  second  and  the  fol- 
licle destroyed.  The  next  day  after  using  the  canter}',  a  whitish  pel- 
licle is  observed  about  this  cauterized  point,  which  may  extend  for  four 
or  five  millimetres  in  every  direction  from  the  burn,  and  appears  very 
much  like  a  diphtheritic  membrane.  This  remains  from  five  to  even 
twelve  days,  depending  upon  the  rapidity  of  the  reparative  process  and, 
perhaps,  atmospheric  conditions.     Frequently  the  patients  retch  and 


Fig.  91.— Ingals1  Cautery  Electrodes  (3-5  size).  1,  Guarded  electrode  used  for  superficial 
cauterization  in  hay  fever  ;  2,  knife-like  electrode  used  in  hypertrophic  rhinitis  ;  3,  4,  and  5,  electrodes 
for  cauterizing;  the  tonsils,  follicles  in  pharynx,  and  small  spots  in  the  nose  ;  5,  electrode  for  base  of 
tongue,  or.  when  guarded  by  a  piece  of  vulcanite  fibre,  for  naso-pharynx  ;  5,  6,  and  7.  tubular  elec- 
trodes, into  which  various  shaped  points  of  platinum  wire  may  be  inserted  for  various  purposes. 

gag  easily,  and  in  such  cases  it  is  evident  how  difficult  it  would  be  to  use 
the  actual  cautery.  Where  there  are  enlarged  veins,  it  is  better  to  cut 
them  off  with  silver  nitrate  or  the  galvano-cautery — the  latter  being 
much  the  more  satisfactory  in  its  action.  Though  the  exudative  form 
of  the  disease  has  been  considered  peculiarly  obstinate,  it  has,  in  my  ex- 
perience, proved  less  stubborn  than  some  other  forms,  when  treated  by 
the  galvano-cautery  in  the  manner  just  described.  Cases  of  simple 
chronic  congestion  without  enlargement  of  the  follicles  are  most  difficult 
to  cure.  In  these  all  sources  of  irritation  must  be  avoided,  and  the 
patient  should  make  applications  to  the  pharynx  of  some  mild  astrin- 
gent two  or  three  times  daily.  Sometimes  such  patients  will  find  it  nec- 
essary to  remove  to  a  different  climate  before  relief  is  found,  but  ordi- 
narily it  is  not  well  to  advise  such  a  course,  for  the  climatic  influence  is 
very  uncertain. 


CHRONIC  FOLLICULAR   GLOSSITIS.  347 


ACUTE   FOLLICULAR    GLOSSITIS. 

Acute  follicular  glossitis  is  an  inflammation  of  the  follicles  at  the 
base  of  the  tongue,  in  which  severe  pain  is  caused  by  an  attempt  at 
deglutition.  Its  causes  are  probably  not  unlike  those  of  acute  follic- 
ular pharyngitis,  and  its  pathology  is  also  similar. 

Symptomatology. — Pain  is  felt  not  only  in  the  throat,  but  radiating 
to  the  ears,  and  some  patients  speak  of  it  as  being  almost  altogether  in 
the  ears,  or  near  the  orifices  of  the  Eustachian  tubes.  Upon  examina- 
tion of  the  parts,  we  may  find  several  small,  rounded  elevations  of  a 
whitish  hue  somewhat  resembling  pustules,  which  may  be  distributed 
all  over  the  base  of  the  tongue,  or  confined  to  one  or  the  other  side, 
particularly  to  that  jnortion  of  the  base  which  is  often  hidden  from  view 
by  contact  with  the  external  wall. 

In  some  cases,  instead  of  these  small  follicles,  one  or  more  superficial 
ulcers  are  to  be  found.  I  have  seen  one  at  least  a  centimetre  in  diame- 
ter, where  small  ulcers  had  coalesced  after  rupture  of  several  follicles. 
These  ulcers  are  more  apt  to  be  found  at  the  side  of  the  base  of  the 
tongue,  where  they  may  escape  notice  except  upon  careful  inspection. 

Diagnosis. — The  disease  is  liable  to  be  mistaken  for  inflammation 
in  the  naso-pharynx,  because  the  patient  often  refers  the  pain  to  that 
locality.  The  diagnosis  will  be  made  by  a  careful  laryngoscopic  inspec- 
tion of  the  base  of  the  tongue,  particularly  of  its  sides,  which  must  be 
exposed  by  crowding  the  organ  over  with  a  spatula. 

Peognosis. — Left  to  itself,  the  condition  lasts  a  week  or  ten  days. 

Teeatment. — The  most  satisfactory  treatment  consists  in  the  appli- 
cation of  a  sixty  grain  solution  of  silver  nitrate  to  the  follicles  or  super- 
ficial ulcers.  The  rapidity  with  which  the  affection  may  be  cured  by 
this  method  is  sometimes  surprising.  I  recollect  one  case  especially, 
where  an  ulcer  a  centimetre  in  diameter  was  found,  in  which  the  pain 
was  relieved  within  a  few  minutes  after  the  first  application,  and  in 
forty-eight  hours  the  ulcer  practically  healed. 


CHRONIC   FOLLICULAR  GLOSSITIS. 

Chronic  follicular  glossitis  is  not  infrequently  associated  with  chronic 
tonsillitis,  and  is  characterized  by  chronic  inflammation  of  the  follicles 
at  the  base  of  the  tongue,  which  become  more  or  less  filled  with  secre- 
tion producing  numerous  yellowish  white  spots  similar  to  diseased  folli- 
cles in  the  tonsils,  and  attended  by  various  uncomfortable  sensations 
referred  either  to  the  tonsils  or,  more  accurately,  to  the  base  of  the 
tongue.  The  nature  of  the  affection  is  essentially  the  same  as  that  of 
chronic  follicular  inflammation  of  the  tonsils,  and  it  is  apparently  de- 
pendent upon  like  causes. 


348  DISEASES  OF  THE  FAUCES. 

Symptomatology. — The  principal  symptoms  of  which  the  patient 
complains  are  sensations  of  pricking  or  of  a  foreign  body  in  the  throat, 
which  may  be  present  continuously  or  only  a  part  of  the  time,  and  which 
may  or  may  not  be  aggravated  by  the  act  of  deglutition. 

DIAGNOSIS. — The  diagnosis  is  made  by  an  examination  of  the  base  of 
the  tongue  with  the  laryngeal  mirror,  without  which  it  is  seldom  possi- 
ble to  see  the  diseased  follicles. 

PROGNOSIS. — The  affection  tends  to  run  on  for  many  months  or  years, 
during  which  time  the  patient  is  much  annoyed  by  offensive  breath  and 
by  harassing  fears  of  tuberculosis  or  cancer. 

Treatment. — When  due  to  a  rheumatic  diathesis,  or  to  disturbance 
of  the  digestive  organs,  the  treatment  suited  to  these  disorders  is  indi- 
cated. 

Locally,  astringent  troches  as  represented  by  the  troches  of  krameria 
(Form.  38  and  -il)  are  sometimes  beneficial,  and  applications  of  more 
active  astringents,  of  stimulants,  or  of  strong  solutions  of  silver  nitrate 
sometimes  prove  curative.  A  more  efficient  method,  and  one  which 
finally  must  be  the  resort  in  most  cases,  is  cauterization  with  the  galvano- 
cautery.  This  is  usually  followed  by  the  most  satisfactory  results.  Two 
or  three  follicles  should  be  cauterized  at  each  sitting,  by  a  small  electrode, 
which  should  be  passed  to  the  bottom  of  each,  and  the  operation  should 
not  be  repeated  until  two  or  three  days  after  all  soreness  from  the  previ- 
ous cauterization  has  disappeared.  This  treatment  should  be  continued 
until  all  of  the  diseased  follicles  have  been  dealt  with  and  a  complete 
cure  may  be  confidently  predicted. 

SCROFULOUS   SORE   THROAT. 

Scrofulous  sore  throat  is  a  chronic  inflammation,  sometimes  observed 
in  scrofulous  children,  which  in  the  simple  form  has  the  appearance  of 
ordinary  catarrhal  inflammation;  when  more  pronounced,  it  resembles 
the  inflammation  of  tuberculosis  or  syphilis.  In  many  instances  it  con- 
sists of  simple  inflammatory  thickening  of  the  mucous  membrane  of  the 
fauces  and  naso-pharynx  or  palate,  but  in  the  more  advanced  conditions — 
which,  indeed,  are  the  only  ones  rightly  classed  under  this  head — ulcer- 
ation occurs.  This  at  first  superficial  and  always  indolent,  finally  be- 
comes extensive,  sometimes  spreading  over  a  large  portion  of  the  pharynx 
or  involving  the  palate,  and  causing  perforation,  or  even  destruction  of 
the  uvula  with  considerable  portions  of  the  velum. 

Etiology. — J.  Solis  Cohen  (Diseases  of  the  Throat)  believes  that 
most  of  these  are  cases  of  simple  chronic  inflammation  occurring  in 
those  of  inherited  syphilitic  taint,  while  others  regard  it  as  a  manifesta- 
tion of  lupus.  Still  others  ascribe  some  of  the  cases  to  tuberculosis  or 
the  rheumatic  or  arthritic  diathesis.  Whatever  the  remote  cause,  it  is 
certain  that  a  low  form  of  inflammation,  with  ulceration,  occurs  in  chil- 


SCROFULOUS  SORE  THROAT.  349 

dren  presenting  what  was  formerly  known  as  the  scrofulous  diathesis; 
aud  it  is  more  than  possible  that,  in  most  of  these,  hereditary  syphilis  or 
tuberculosis  could  be  traced  if  an  accurate  history  could  be  obtained. 

Symptomatology. — There  are  no  positive  symptoms  or  signs  of  this 
affection,  but  usually  the  child  is  pale  and  less  vigorous  than  other  chil- 
dren of  the  same  age  and  surroundings;  there  is  sometimes  a  tendency 
to  clear  the  throat  of  secretions  frequently,  but  usually  this  is  not  a 
pronounced  symptom,  and  even  when  extensive  ulceration  has  taken 
place  the  patient  does  not  complain  of  pain.  Difficulty  in  deglutition  or 
alteration  of  the  voice  may  be  caused  by  partial  destruction  of  the  soft 
palate  or  extensive  ulceration  of  the  pharynx.  Sometimes  a  history  of 
inherited  syphilis  or  tuberculosis  can  be  obtained,  and  upon  examination 
of  the  fauces  more  or  less  extensive  ulceration  will  be  found.  These 
ulcers  are  at  first  superficial,  but  later  are  deep,  with  bevelled  edges,  in- 
dolent surface,  and  slight  discharge. 

Diagnosis. — Scrofulous  sore  throat  is  to  be  distinguished  from  lupus, 
tuberculosis,  and  syphilis. 

External  manifestations  which  may. at  once  decide  the  diagnosis, 
nearly  always  attend  lupus.  Upon  the  base  and  about  the  edges  of  the 
ulcer  are  red  nodules,  which  do  not  appear  in  the  scrofulous  ulceration. 

Scrofulous  sore  throat  is  distinguished  from  tuberculosis  by  the 
comparative  absence  of  pain,  by  a  well  marked  instead  of  an  indistinct 
border,  by  the  absence  of  fever  and  other  evidences  of  tuberculosis. 

Scrofulous  sore  throat  is  distinguished  from  syphilitic  ulceration  of 
the  throat  by  the  absence  of  a  syphilitic  history  and  the  general  signs  of 
the  disease,  by  the  age  of  the  patient,  slow  progress  of  the  ulceration, 
slight  discharge  and  bevelling  of  its  edges,  which  do  not  have  the  punched- 
out  appearance  common  in  syphilis. 

Scrofulous  sore  throat  and  lupus  of  the  pharynx  present  the  following 
points  of  difference: 

Scrofulous  sore  throat.  Lupus  of  the  pharynx. 

Generally  seen  in  children.     Usually  Generally  in  young- adults.   Usually 

evidences    of    constitutional    disturb-        associated  with  disease  of  the  face, 
ance. 

Ulcers  superficial  or  deep,  with  bev-  Congested,  irregular  nodules  about 

elled  edges,  indolent  base,  and  slight  edges  or  on  base  of  ulcers,  which  are 
discharge;  no  cicatrices.  usually    extending    in    some    places, 

while  healing  at  some  other  part  of 
their  border;  usually  old  cicatrices. 

Scrofulous  sore  throat  and  syphilitic  -sore  throat  can  be  differentiated 
as  follows: 

Scrofulous  sore  throat.  Syphilitic  sore  throat. 

Generally  seen  in  children.     Ulcer  in-  Generally  seen  in    adults.      Ulcer 

dolent  and  usually  has  a  bevelled  edge  sharp  cut,  indurated,  sometimes  un- 

not  indurated  or  undermined.  dermined. 


350  DISEASES   OF  THE  FAUCES. 

The  differential  diagnosis  of  tubercular  sore  throat  and  scrofulous 
sore  throat,  will  be  further  considered  under  the  head  of  acute  tubercular 
sore  throat. 

Prognosis. — If  left  to  itself,  the  ulceration  gradually  extends,  and 
may  continue  for  many  months;  I  have  seen  cases  which  had  lasted  for 
over  a  year.  With  improvement  of  the  general  condition  and  appropri- 
ate local  treatment,  healing  may  be  expected  within  a  short  time. 

Treatment. — Good  hygienic  surroundings  and  tonics  are  most  im- 
portant. Calcium  iodide  and  chloride  internally  in  moderate  doses  are 
beneficial,  and  cod-liver  oil  is  generally  recommended.  The  local  treat- 
ment consists  of  frequent  cauterization  or  stimulation  by  less  active 
agents.  In  practice,  the  thorough  application  of  strong  tincture  of 
iodine  to  the  ulcer  two  or  three  times  a  week  has  given  best  satisfaction. 
Under  its  influence  and  the  general  treatment,  healing  soon  begins,  and 
an  ulcer  an  inch  in  diameter  may  be  expected  to  heal  within  six  or  eight 
weeks. 

ACUTE  TUBERCULAR  SORB  THROAT. 

Acute  tubercular  sore  throat  is  a  rare  affection  occurring  in  about 
one  per  cent  of  all  cases  of  tuberculosis  of  the  respiratory  tract  (Browne, 
Diseases  of  the  Throat,  third  edition).  It  runs  a  rapid  course,  being  char- 
acterized by  ulceration  and  great  pain  and  the  constitutional  symptoms 
of  tuberculosis. 

Anatomical  axd  Pathological  Characteristics. — At  first  there 
appear  numerous  small,  gray  granulations  grouped  in  patches  beneath 
the  epithelium,  and  if  abundant,  closely  resembling  the  mucous  patches 
of  syphilis,  but  they  lack  the  inflammatory  areola?  which  are  found  about 
the  latter.  These  granulations  are  said  to  bleed  easily  when  touched, 
but  this  has  not  been  my  experience.  They  may  be  located  upon  the 
palate  and  the  pharynx,  and  late  in  the  disease  may  be  found  on  the  epi- 
glottis and  in  the  larynx.  As  the  affection  progresses  they  lose  their 
transparency,  become  hidden  in  a  purulent  or  pultaceous  covering,  and 
finally  undergo  ulceration.  These  ulcerations  are  shallow,  have  no  well 
marked  borders,  but  rather  a  worm  eaten,  irregular  edge,  and  bleed  easily 
when  touched. 

Etiology. — The  cause  is  the  same  as  that  of  tuberculosis  in  other 
localities. 

Symptomatology. — Usually  there  are  evidences  of  primary  pulmo- 
nary or  laryngeal  phthisis.  The  consumptive  appearance,  persistent  fever, 
rapid  pulse,  cough  with  or  witnout  expectoration,  anorexia,  and  other 
symptoms  of  tuberculosis  are  apt  to  be  marked,  but  the  pharyngeal 
lesions  may  be  independent  of  laryngeal  or  pulmonary  disease,  these 
subsequently  supervening.  The  one  prominent,  sometimes  the  first, 
symptom  of  tubercular  sore  throat  is  intense  pain,  sometimes  experienced 
upon  phonation  and  upon  attempts  at  deglutition.     It  becomes  agonizing, 


ACUTE  TUBERCULAR  SORE  THROAT.  351 

largely  preventing  the  taking  of  food,  with  consequent  speedy  loss  of 
strength  and  rapid  advance  of  the  disease.  An  early  examination  may 
reveal  congestion  of  the  pharynx  similar  to  that  found  in  simple 
inflammation,  but  in  most  cases  the  mucous  membrane  presents  a 
characteristic  grayish  pallor  with  numerous  semi-transparent  granula- 
tions which  speedily  give  place  to  ulceration.  The  tubercular  ulcer  is 
superficial,  with  irregular  ill  defined  borders,  which  are  not  undermined, 
and  it  is  sometimes  surrounded  by  a  faint  blush,  though  usually  there  is 
no  areola  of  hyperemia.  The  floor  presents  indolent,  gray  granulations* 
and  scanty  secretions. 

In  exceptional  cases  the  tubercular  ulcer  has  a  sharply  defined 
border,  which  may  be  slightly  thickened  and  congested;  it  has  a  depth 
of  about  one  and  one-half  millimetres,  and  its  base  is  covered  with  a 
grayish  white  coating  presenting  an  appearance  about  midway  between 
that  of  the  ordinary  superficial  ulcer  described  above  and  the  deep  ulcera- 
tion of  syphilis. 

Diagnosis. — Tubercular  sore  throat  may  be  mistaken  for  syphilitic 
or  scrofulous  sore  throat. 

Syphilitic  sore  throat  is  not  accompanied  by  the  excessive  pain,  the 
fever,  and  the  constitutional  symptoms  of  the  tubercular  affection;  and 
instead  of  the  marked  anasmia  of  the  mucous  membrane  and  small  gray 
granulations,  or  shallow  irregular  ulcers  with  ill  defined,  pale  borders, 
and  scanty,  grayish,  viscid  secretion,  it  is  characterized  by  the  large, 
sharply  defined  inflammatory  ulcers  of  the  secondary  stage,  or  the  deep 
ulcers  of  the  tertiary  form  with  raised  and  often  undermined  edges, 
granular  floor,  and  profuse  purulent  secretion.  As  also  noted  by 
Lennox  Browne  (op.  cit.),  the  enlargement  of  the  parotid,  submaxillary, 
and  cervical  glands,  both  superficial  and  deep,  so  commonly  observed 
in  the  tubercular  affection,  is  relatively  infrequent  in  the  latter  part 
of  the  secondary,  and  in  the  tertiary  stage  of  syphilis. 

From  syphilitic  sore  throat,  tubercular  sore  throat  may  be  distin- 
guished as  follows : 

Tubercular  sore  throat.  Syphilitic  sore  throat. 

No  syphilitic  history,     Generally  in  Syphilitic  history.     If  hereditary,  it 

adults.  may  appear  in  children  ;  otherwise  in 

adults. 
Marked  constitutional  symptoms.  Constitutional    symptoms    may    be 

marked. 
Fever,  rapid  emaciation.  Usually  no  fever. 

Severe  local  pain.  Frequently  no  pain. 

Aphonia,  dysphagia.  Hoarseness,  but  usually  no  aphonia 

or  dysphagia. 
Ulcer  usually  superficial,  with  gray-  Ulcer  sharp  cut,  with  areola  of  red- 

ish,  worm  eaten  appearance  and  rapidly        dened,  thickened  tissue  about  it,  some- 
progressive,  times  undermined  edge. 
Short  duration.  May   progress    rapidly  but  usually 

relatively  longer  in  duration. 


DISEASES   OF  THE  FAUCES. 

Scrofulous  sore  throat,  unlike  the  tubercular,  occurs  in  children  in- 
stead of  young  adults,  and  lacks  the  severe  pain,  the  fever,  and  the  irreg- 
ular, superficial,  poorly  defined  ulcers  of  the  latter  affection. 

Between  tubercular  sore  throat  and  scrofulous  sore  throat  the  follow- 
ing are  the  chief  points  of  difference : 

Tubercular  sore  throat.  Scrofulous  sore  throat. 

Rarely  seen  in  children.    Ulcer  super-  Generally  seen  in  children.     Ulcer 

ficiul,  with  poorly  defined  borders.  deep,  with  sharply  defined  edges. 

Hectic  fever.     Considerable  cough.  No  fever.     Little  or  no  cough. 

Rapid  emaciation.  Slow  physical  change. 

Severe    pain,    frequently     the    first  But  little  or  no  pain, 
symptom. 

Dyspnoea,    dysphonia    or     aphonia,  No  dysphonia,  aphonia,  or  dyspha- 

dysphagia.  gia. 

Pulmonary  tuberculosis  usually  pres-  No  signs  of  pulmonary  tuberculosis, 
ent. 

Prognosis. — Tubercular  sore  throat  usually  runs  its  course  in  from 
six  to  twelve  weeks,  and  nearly  always  terminates  fatally.  In  exceptional 
instances  the  duration  is  as  much  as  six  months,  and  in  extremely  rare 
cases  recovery  may  occur,  or  the  disease  may  progress  slowly,  the  patient 
under  favorable  conditions  living  for  several  years  before  succumbing  to 
the  constitutional  disease.     Death  is  caused  commonly  by  asthenia. 

Treatment. — The  treatment  recommended  by  Krause  and  Herying, 
by  thorough  curetting  the  ulcers,  followed  by  the  application  of  lactic 
acid,  with  occasional  use  of  the  galvano-cautery,  has  effected  a  few  cures 
(Gleitsmann,  New  Tori-  Medical  Journal,  1891),  and  similar  results  have 
been  attained  by  the  use  of  lactic  acid  alone  in  solutions  varying  in 
strength  from  twenty  to  seventy-five  per  cent.  Sedative  applications  are 
of  much  benefit,  chief  among  which  are  steam  impregnated  with  bella- 
donna, hyoscyamus,  stramonium,  or  opium,  as  recommended  (Form.  56, 
57,  and  59).  Sajous  (Diseases  of  the  Nose  and  Throat)  recommends  a 
ten  per  cent  solution  of  cocaine  applied  often  enough  to  relieve  pain ;  but 
the  evil  effects  of  this  drug  are  so  pronounced  that  extreme  caution  should 
be  used  in  its  employment.  Painting  the  throat  with  solutions  of  silver 
nitrate  as  advised  by  some,  has  usually  proven  more  hurtful  than  other- 
wise. I  have  found  most  satisfactory,  for  relieving  pain,  a  spray  of  mor- 
phine, carbolic  acid,  and  tannic  acid  (Form.  93).  This  may  be  used  by 
the  patient  also,  diluted,  with  one  or  more  parts  of  water,  according  to 
the  amount  of  smarting  occasioned.  Troches  of  morphine  or  lactuca- 
rium,  or  althea  (Form.  25,  29,  and  36)  are  sometimes  efficient  in  reliev- 
ing the  distress,  bat  the  good  effect  of  opiates  is  usually  counteracted  by 
the  excessive  dryness  which  they  cause.  When  dysphagia  becomes  ex- 
treme, the  feeding  bottle  may  be  used,  as  recommended  by  Delavan 
(Transactions  of  the  Ninth  American  Laryngological  Association)    or 


SYPHILITIC  SURE  THROAT.  353 

nutritive  enema ta  may  be  employed,  but  in  well  marked  cases  all  that 
we  can  hope  for  is  to  render  the  patient  as  comfortable  as  possible. 

SYPHILITIC  SORE   THROAT. 

Syphilis  may  affect  the  fauces  in  any  of  its  three  stages,  but  the 
earliest  manifestation  is  seldom  seen  in  the  throat,  though  the  secondary 
and  tertiary  forms  are  common.  The  chancre  or  primary  lesion  of 
syphilis,  when  present  in  the  mouth,  is  similar  to  that  which  may  occur 
in  other  parts,  and  lasts  for  five  or  six  weeks;  in  the  secondary  stage  the 
erythematous  or  mucous  patches,  and  in  the  tertiary  stage  gummata  or 
deep  ulcers,  are  characteristic.  When  the  disease  is  inherited,  the  sec- 
ondary symptoms  usually  occur  within  two  to  six  weeks  after  birth ;  the 
tertiary,  in  early  childhood  or  at  any  time  before  the  sixteenth  year. 

Anatomical  axd  Pathological  Characteristics. — When  chan- 
cre occurs  in  the  throat,  it  is  nearby  always  located  on  one  tonsil.  In 
the  secondary  affection,  usually  at  first  the  fauces  present  a  uniform  dull 
red  erythema;  this  in  part  gradually  fades  away,  leaving  erythematous 
patches  which  tend  to  symmetrical  arrangement  upon  the  two  sides  of 
the  palate  or  pillars  of  the  fauces,  and  sometimes  upon  the  pharyngeal 
wall.  These  patches  are  separated,  from  healthy  tissue  by  a  distinct  line 
of  demarcation.  Mucous  patches  (also  termed  mucous  tubercles  cr 
broad  condylomata)  when  occurring  in  infants,  are  usually  found  in  the 
upper  part  of  the  pharynx  and  on  the  fauces;  but  in  adults  on  the  pillars 
of  the  fauces,  or  the  velum  palati'and  the  sides  and  base  of  the  tongue. 
They  are  circular  or  elliptical  in  form,  slightly  elevated,  at  first  of  a  deep 
red,  later  of  a  grayish  white  color,  and,  as  a  rule,  symmetrically  situated 
on  each  side  of  the  throat.  These  subsequently  become  the  seat  of 
superficial  ulcers;  their  borders  are  distinctly  marked  and  surrounded 
by  an  areola  of  hyperemia,  slightly  elevated,  and  from  three  to  five 
millimetres  in  width.  Occasionally  deep  and  rapidly  extending  ulcera- 
tion follows;  these  ulcers  are  two  or  three  millimetres  in  depth,  with  a 
light  pinkish  or  grayish  surface,  and  have  sharply  defined  but  not  in- 
durated edges.  In  the  tertiary  stage,  ulcerations  are  deep  and  usually 
preceded  by  gummata.  A  gumma,  situated  as  a  rule  under  the  mucous 
membrane,  is  at  first  small  varying  from  three  to  eight  millimetres  in 
diameter,  and  causes  no  disturbance,  but  as  it  increases  in  size  the 
mucous  membrane  covering  it  becomes  congested,  and  finally,  as  the 
gumma  softens,  a  yellowish  spot  appears  at  the  surface,  soon  to  be  fol- 
lowed by  ulceration. 

Two  varieties  of  ulceration  occur  in  this  stage,  the  superficial  and  the 
perforating.  The  former  is  most  frequently  found  on  the  velum,  but 
is  also  seen  upon  the  pillars  of  the  fauces  and  tonsils;  often  having  a 
depth  of  one  or  two  millimetres.  The  ulcers  have  irregular,  sharply 
defined  borders  and  secrete  foul,  dirty  pus,  which  when  cleared  away 


354  DISEASES  OF  THE  FAUCES. 

reveals  a  floor  pale  and  smooth,  with  here  and  there  fungoid  granulations. 
Fissures  sometimes  extend  from  the  edges  into  the  surrounding  tissue. 
Deep  ulcers  situated  on  any  part  of  the  fauces  or  pharynx  are  com- 
monly from  three  to  five  millimetres  in  depth  with  clear-cut  edges,  often 
undermined  and  indurated.  Ulcers  of  the  third  stage,  whether  sequela? 
of  gummata  or  not,  are  apt  to  extend  rapidly,  destroying  all  tissue  in 
continuity,  not  excepting  cartilage  and  bone.  Frequently  perforation 
of  the  palate  occurs  (Fig.  92)  as  if  by  magic,  sometimes  as  the  result 
of  a  gumma,  which  in  the  palate  occurs  preferably  upon  its  upper  sur- 
face. Such  ulceration  may  destroy  a  considerable  portion  of  the  velum 
within  ten  or  fifteen  days. 

Etiology. — Syphilis,  whether  inherited  or  acquired,  is  probably  due 
to  a  specific  virus,  not  yet  identified. 

Symptomatology. — The  primary  affection  usually  causes  no  symp- 
toms, in  the  throat  unless  phagedenic  ulceration  occurs,  giving  rise  to 
pain  and  fever.     In  the  secondary  stage,  there  is  dryness  of  the  throat, 


Fig.  92.— Perforating  Ulcer  of  Palate,  Syphilitic. 

with  more  or  less  soreness  and  occasionally  a  slight  febrile  reaction.  In 
some  cases,  owing  to  the  location  of  the  ulcer,  there  is  great  pain  upon 
deglutition.  Papillary  eruptions  upon  the  skin  usually  appear  at  this  time. 
The  tertiary  form  sometimes  develops  insidiously,  and  may  have  produced 
great  mischief  without  having  caused  the  patient  much  discomfort.  In 
other  cases,  owing  to  the  location  of  the  ulcer,  severe  pain  is  experienced, 
especially  on  deglutition.  In  such  cases  constitutional  symptoms  are 
then  apt  to  be  pronounced,  and  after  a  few  weeks  the  patient  may  present 
much  the  same  symptoms,  with  fever  and  emaciation,  as  one  suffering 
from  advanced  tuberculosis. 

Diagnosis. — The  primary  affection  is  apt  to  escape  observation,  but 
careful  examination  of  the  throat  may  discover  a  small  ulcer  situated 
on  an  indurated  base  surrounded  by  a  slightly  cedematous,  elevated 
mucous  membrane.  If  this  is  associated  with  a  suspicious  history,  and 
remains  obstinate  to  all  treatment  for  four  or  five  weeks,  we  may  be 
nearly  certain  of  our  diagnosis. 

The  secondary  affection,  in  the  beginning,  is  liable  to  be  mistaken  for 
catarrhal  sore  throat,  but  after  three  or   four    days   the   development 


SYPHILITIC  SORE  THROAT.  355 

of  symmetrical,  erythematous  patches  distinctly  outlined,  or  the  grayish 
elevated  mucous  patches  or  superficial  ulcers,  with  areola?  of  inflamma- 
tion, will  at  once  suggest  the  true  nature  of  the  disease.  However,  even 
then  it  is  possible  to  confound  the  affection  with  simple  membranous  or 
herpetic  sore  throat;  but  the  specific  history,  if  it  can  be  obtained,  or, 
if  not,  the  progress  of  the  case  for  the  next  few  days,  will  settle  the  diag- 
nosis. The  superficial  ulceration  of  this  stage  should  not  be  confounded 
with  acute  tubercular  sore  throat,  if  the  history,  constitutional  symptoms, 
and  appearance  of  the  ulcer  are  taken  into  account. 

The  tertiary  stage  is  liable  to  be  mistaken  for  scrofulous  or  tuber- 
cular sore  throat,  the  distinctive  features  of  which  were  pointed  out  in 
considering  these  diseases.  The  characteristic  features  of  tertiary 
syphilitic  ulceration  of  the  throat  are :  commonly  absence  or  insignificance 
of  pain  and  of  constitutional  symptoms;  also  the  edges  of  the  ulcer  are 
sharp  cut,  indurated,  and  sometimes  undermined,  and  the  process  is  rapid. 

In  a  very  rare  form  of  diphtheroid  syphilitic  ulceration  of  the  throat  I  have 
seen  three  cases  that  have  been  mistaken  for  diphtheria. 

Prognosis. — The  primary  disease  continues  five  or  six  weeks,  and 
then  terminates  spontaneously.  The  secondary  affection  usually  comes 
on  in  from  six  to  twelve  weeks  after  inoculation,  and,  as  a  rule,  disap- 
pears in  from  six  to  eight  weeks,  or  sooner  under  proper  treatment;  but 
sometimes  renewed  eruptions  make  their  appearance  from  time  to  time 
for  several  months.  The  gummata  of  the  tertiary  stage  sometimes  dis- 
appear as  they  came,  but  usually  soften  and  ulcerate,  the  ulcers  spread- 
ing rapidly  for  two  or  three  weeks  afterward;  subsequently  they  may 
continue  to  progress  more  slowly  for  several  months  if  left  to  them- 
selves. The  primary  affection  makes  little  impression  on  the  general 
health;  the  secondary  is  seldom  dangerous  to  life,  but  the  tertiary  is 
often  grave.  The  ulceration  in  the  latter  may  perforate  the  hard  palate 
and  destroy  large  portions  of  the  soft  tissues,  and  may  sometimes  cause 
death  by  erosions  of  a  large  blood  vessel  or  by  narrowing  of  the  air  passages. 
Cicatrization  after  ulceration  frequently  narrows  or  completely  closes 
the  opening  to  the  naso-pharynx  or  causes  stenosis  of  the  larynx,  inter- 
fering with  respiration  and  phonation.  Destruction  of  the  palate  in- 
terferes with  phonation,  and  with  deglutition  by  allowing  fluid  to  re- 
gurgitate through  the  nose.  Adhesion  of  the  base  of  the  tongue  to  the 
pharyngeal  wall  sometimes  seriously  interferes  with  both  respiration  and 
deglutition.  In  one  case  which  has  come  under  my  observation,  an 
opening  was  left  only  two  or  three  millimetres  in  width  by  six  or  eight 
in  length.  Under  appropriate  treatment  the  majority  of  cases  can  be 
relieved  and  the  disease  checked,  but  sometimes,  in  spite  of  everything, 
it  goes  on  or  the  exacerbations  frequently  recur  until  death  results. 

Teeatmext. — For  the  primary  affection  cauterization  is  recom- 
mended by  some,  while  others  favor  a  negative  course.     Even  for  the 


356  DISEASES   OF  THE  FAUCES. 

secondary  lesions  some  are  in  favor  of  confining  the  treatment  in 
the  majority  of  cases  to  local  measures.  Mackenzie  (Diseases  of  the 
Throat  and  Nose,  Vol.  I.)  seldom  uses  constitutional  remedies  in  the 
secondary  stage,  relying  mainly  upon  local  applications  of  the  zinc  chlo- 
ride gr.  xx.,  ad  3  i.  for  the  erythematous  eruption,  or  the  tincture  of 
iodine  for  mucous  patches,  but  he  recommends  mercurials  for  the  in- 
herited syphilis  and  in  obstinate  cases  of  the  acquired  affection.  Sajous 
(Diseases  of  the  Nose  and  Throat)  advises  for  the  secondary  affection 
local  applications  of  silver  nitrate,  iodoform,  and  tincture  of  the  chloride 
of  iron.  For  the  secondary  affection,  I  usually  employ  a  spray  of  zinc 
chloride  gr.  xxx.  ad  \  i.  two  or  three  times  a  week,  directing  the  pa- 
tient to  use  at  home  the  same  remedy  twice  daily  in  the  form  of  spray 
gr.  x.  ad  i  i.  For  the  mucous  patches  I  sometimes  rely  upon  these  ap- 
plications, and  at  others  I  use  the  strong  tincture  of  iodine  or  a  solution 
of  copper  sulphate  gr.  xx.  ad  §  i.,  having  the  patient  use  the  spray  at 
home  as  just  recommended.  Usually  small  doses  of  mercury  bichloride 
and  potassium  iodide  are  administered  after  each  meal,  and  in  many 
cases  ferruginous  or  bitter  tonics  are  given  before  eating,  depending 
upon  the  patient's  general  condition.  For  the  ulcers  of  tertiary  syphilis 
the  strong  tincture  of  iodine  is  the  most  efficient  application,  though 
occasionally  the  sulphate  of  copper,  as  recommended  above,  willbefound 
useful.  Much,  I  believe,  depends  upon  the  manner  of  applying  the 
tincture  of  iodine.  The  ulcer  should  be  touched  repeatedly  at  each 
sitting  (four  to  eight  times),  and  a  minute  allowed  between  each  applica- 
tion for  the  parts  to  dry.  When  the  application  is  completed  the  sur- 
face of  the  ulcer  should  appear  dry  and  glazed  and  of  a  dark  brown 
color.  These  treatments  should  be  repeated  daily  for  ten  to  fifteen  days 
and  subsequently  less  frequently  until  the  parts  are  healed.  At  the 
same  time  the  patient  should  be  given  the  iodides  of  sodium  and  potas- 
sium in  doses  of  from  5  to  10  grains  each  three  or  four  times  a  day. 
Under  this  treatment  even  lame  chronic  ulcers  may  be  expected  to 
heal  in  from  two  to  four  weeks.  If  there  is  a  tendency  to  closure 
of  the  entrance  to  the  naso-pharynx,  or  other  vicious  adhesions  are 
forming,  bougies  should  be  passed  frequently  until  complete  cicatriza- 
tion has  occurred;  but  this  should  not  be  attempted  until  the  reparative 
process  has  been  fully  established.  It  is  especially  important  to  be 
faithful  in  dilatation  just  as  the  last  vestiges  of  the  ulcer  are  disappear- 
ing, for  at  this  time  contraction  takes  place  with  wonderful  rapidity. 

Syphilitic  sore  throat  in  infants,  is  a  congenital  manifestation 
of  syphilis  usually  characterized  by  ulceration,  the  favorite  seat  of  which 
is  the  palate,  naso-pharynx,  or  posterior  pharyngeal  wall.  According  to 
J.  X.  Mackenzie,  of  Baltimore,  nearly  fifty  per  cent  of  the  cases  occur 
within  the  first  year  of  life,  and  as  many  as  thirty-three  per  cent  within 
the  first  six  months.  In  some,  however,  the  development  is  delayed  until 
near  the  age  of  puberty. 


SYPHILITIC  SORE  THROAT.  357 

Anatomical  and  Pathological  Characteristics.  —  Mucous 
patches  are  rare,  this  stage  having  probably  been  passed  in  intra-uterine 
life ;  when  found,  these  patches  are  apt  to  be  located  in  the  upper  por- 
tion of  the  pharynx.  Ulceration  is  more  commonly  present,  its  favorite 
seat  in  order  of  frequency  being  the  fauces,  naso-pharynx,  posterior 
pharyngeal  wall,  nasal  fossae,  septum,  tongue,  and  finally  the  gums.  The 
ulcers  present  the  appearance  of  tertiary  syphilis  in  adults,  already  de- 
scribed, and  are  peculiarly  prone  to  attack  the  bones  and  cartilages. 

Etiology. — The  affection  is  either  inherited  during  the  intra-uterine 
life  or  contracted  during  parturition. 

Symptomatology. — This  condition  of  the  throat  is  usually  associated 
with  syphilitic  lesions  in  the  nose,  giving  rise  to  embarrassment  of  the  nasal 
respiration  and  difficulty  in  nursing.  This  in  a  short  time  is  followed 
by  a  serous  discharge  from  the  nose,  that  becomes  thick  and  purulent, 
sometimes  sanguinolent  within  a  few  days.  The  lips  are  frequently  ex- 
coriated, and  specific  fissures,  pustules,  and  ulcers  develop  upon  the  alaa 
of  the  nose,  the  lips,  and  angles  of  the  mouth,  extending  outward  upon 
the  cheek.  Ulceration  of  the  pharynx  also  may  seriously  interfere  with 
deglutition. 

Diagnosis. — The  disease  is  distinguished  from  simple  catarrhal  in- 
flammation by  the  profuse  discharge  from  the  nose,  the  obstruction  to 
nasal  respiration,  the  occurrence  of  pustules  and  ulcers  upon  the  lips, 
and  the  peculiar  ulceration  in  the  pharynx. 

Prognosis. — When  occurring  within  the  first  year  of  life  the  disease 
is  nearly  always  fatal.  Older  children  may  recover,  but  are  apt  to  be 
left  with  disfigurement  of  the  nose  and  partial  destruction  of  the  palate 
with  consequent  interference  with  the  voice  and  respiration.  Often  deaf- 
ness results.  The  later  the  appearance  of  the  disease,  the  better  the 
chance  of  cure;  but  it  is  apt  to  break  out  anew  from  time  to  time. 

Treatment. — The  treatment  is  essentially  the  same  as  for  adults, 
though  children  bear  mercurials  better.  Local  applications  should  be  so 
mild  as  to  cause  but  little  pain. 


CHAPTER   XXI. 

DISEASES   OF   THE   FAUCES.— Continued. 

DISEASES   OF   THE   UVULA. 

ACUTE     INFLAMMATION     AND    (EDEMA    OF   THE    UVULA. 

Acute  (edematous  inflammation  of  the  uvula  is  a  rare  affection  ex- 
cept as  associated  with  pharyngitis  or  tonsillitis.  It  usually  causes  but 
little  pain,  but  is  attended  by  some  discomfort  in  eating  and  by  frequent 
desire  to  swallow.  The  uvula  when  (edematous  sometimes  becomes  so 
large  as  to  interfere  with  respiration,  and  if  it  be  long  enough  to  touch 
the  base  of  the  tongue  or  epiglottis  it  causes  an  irritating  throat  cough. 
The  affection  is  not  difficult  of  recognition. 

Treatment. — The  proper  treatment  consists  in  the  application  of 
astringent  sprays  or  the  use  of  astringent  troches  or  gargles,  and,  if  the 
oedema  is  great,  a  few  punctures  may  be  made  near  the  lower  end  of 
the  uvula  to  allow  the  serum  to  escape,  but  the  organ  should  not  be  cut 
off  during  the  acute  inflammation  unless  it  seriously  interferes  with 
respiration  or  deglutition,  and  then  only  a  part  ought  to  be  removed.  If 
the  punctures  are  not  sufficient  to  allow  the  serum  to  escape,  the  re- 
moval of  a  small  bit  of  mucous  membrane  from  the  tip  of  the  organ  is 
generally  effectual. 

CHRONIC    INFLAMMATION    AND    ELONGATION    OF    THE   UVULA. 

Elongation,  though  sometimes  occurring  without  chronic  inflamma- 
tion, is  generally  associated  with  it.  It  is  apparently  due  to  the  same 
causes  as  chronic  pharyngitis  or  tonsillitis.  Sometimes  it  takes  place 
without  any  appreciable  cause.  In  health  the  uvula  is  from  one-fourth 
to  three-eighths  of  an  inch  in  length.  Sometimes  when  diseased,  it  may 
become  three-fourths  of  an  inch  in  length  without  causing  inconvenience; 
but  in  other  patients,  even  moderate  elongation  causes  frequent  desire 
to  clear  the  throat,  with  expectoration  of  small  masses  of  mucus,  and  an 
irritating  cough  which  occasionally  becomes  so  excessive  as  to  interfere 
with  the  patient's  rest,  and  in  rare  instances,  by  this  means,  to  bring  on 
symptoms  similar  to  those  of  serious  pulmonary  disease.  An  elongated 
uvula  sometimes  causes  spasmodic  attacks  of  retching  and  vomiting  and 
occasionally  reflex  spasm  of  the  glottis.     The   symptoms  are   usually 


MALFORMATIONS  AND  NEW  GROWTHS  OF  THE  UVULA.     359 

worse  when  the  patient  lies  down.  In  a  few  cases  it  gives  rise  to  pain 
and  fatigue  after  using  the  voice,  and  more  rarely  to  hoarseness. 

Diagnosis. — Elongation  of  the  uvula  may  be  easily  detected  by  in- 
spection. 

Treatment. — When  all  other  causes  of  the  symptoms  have  been 
excluded,  the  superfluous  part  of  the  organ  should  be  removed  by  the 
uvulatome,  scissors  (Fig.  93),  or  the  nasal  snare  (Fig.  208).  Various  uvula- 
tomes  have  been  devised  for  the  purpose,  but  they  are  not  better  than  the 
scissors  shown  in  Fig.  93,  which  are  simple  and  well  suited  to  the 
purpose.  The  nasal  snare  will  be  found  much  more  convenient.  By 
it,  abscission  can  be  doue  more  accurately,  and  excessive  bleeding  is 
less  likely  to  occur.  The  snare  for  this  purpose  is  armed  with  Xo.  5 
steel  wire,  a  loop  just  large  enough  to  easily  enclose  the  tip  of  the 
uvula  is  formed,  the  physician  depresses  the  tongue  with  one  hand, 
and  with  the  other  slips  the  snare  under  the  tip  of  the  uvula,  carrying 
it  up  to  within  from  one-half  to  three-eighths  of  an  inch  of  its  base.     If 


^HP.W  &w\h 


Fig.  93.— SrtssoRS  for  Amputating  the  Uvula  (J^size). 

the  uvula  appears  swollen  at  the  time,  less  should  be  removed  than 
otherwise,  and  it  is  best  never  to  make  it  shorter  than  normal.  The 
wire  is  tightened  down  until  the  tissue  is  secured,  then  the  tongue 
depressor  is  removed,  and  the  physician,  seizing  the  cross  bar  of  the 
snare  with  his  left  hand,  suddenly  draws  upon  the  wire  with  the 
combined  strength  of  the  fingers  of  both  hands,  cutting  through  the  tis- 
sue as  quickly  as  by  a  knife.  After  the  operation,  the  patient  should 
be  supplied  with  troches  of  althea  to  use  as  often  as  desired  to  soothe 
the  pain,  and  a  one  per  cent  gargle  of  carbolic  acid  may  be  advanta- 
geously used  several  times  daily  until  the  wound  has  healed.  In  a  few  in- 
stances alarming  hemorrhage  has  taken  place  after  cutting  off  the  uvula. 


ilALFORMATIOXS    AXD    NEW     GROWTHS    OF    THE    UVULA. 

The  uvula  may  be  asymmetrical  or  absent,  but  the  most  frequent 
malformation  is  bifurcation.  This  requires  no  treatment  unless  the 
organ  is  also  elongated,  when  a  portion  should  be  removed. 

Papillary  growths  are  not  infrequently  found  on  the  uvula,  and  if 
large,  by  their  mechanical  effects  they  may  give  rise  to  the  same  symp- 
toms as  elongation.  They  are  easily  diagnosticated,  and  may  be  readily 
removed  bv  the  snare. 


360  DISEASES   OF  THE  FAUCES. 

Malignant  growths  rarely,  if  ever,  first  attack  the  uvula,  though  it 
may  be  involved  by  extension  of  the  disease  from  the  tonsils  and  palate. 
The  organ  is  often  involved  in  syphilitic  inflammation  and  ulceration, 
but  these  cases  require  no  special  consideration,  as  they  were  sufficiently 
described  in  speaking  of  diseases  of  the  adjacent  parts. 


LEUCOPLAKIA    BUCCALIS. 

Synonyms. — Leucoplakia  buccalis  et  lingualis,  ichthyosis  lingua?. 

Leucoplakia  buccalis  is  a  chronic  affection  of  the  buccal  mucous 
membrane,  characterized  by  thickening  of  the  epithelium  and  the  forma- 
tion of  white,  opaline,  elevated  patches,  which  usually  become  fissured 
and  painful,  and,  after  continuing  for  a  long  time,  are  inclined  to  ter- 
minate in  epithelioma.  The  disease  is  very  rare,  occurring  almost  in- 
variably in  men  over  forty  years  of  age. 

Anatomical  axd  Pathological  Characteristics. — The  patches 
are  limited  to  the  buccal  cavity,  and  are  generally  found  on  the  dorsum 
of  the  tongue  or  inner  surface  of  the  cheeks  and  lips,  but  seldom,  if  ever, 
on  the  lower  surface  of  the  tongue  or  back  of  the  anterior  pillars  of  the 
fauces.  They  consist  of  one  or  more  small,  irregular  or  oval  spots  which 
may  become  confluent.  A  considerable  portion  of  the  tongue  alone  may 
be  involved,  or  the  dorsum  of  the  tongue,  buccal  mucous  membrane,  and 
the  gums,  one  or  all  may  be  affected.  The  first  appearance  of  the  white 
patch  is  preceded  by  hyperemia,  and  subsequently  in  the  early  stages  a 
hyperamiic  areola  is  found  about  its  borders.  Before  long  the  patch 
itself  becomes  thickened,  sometimes  to  the  extent  of  six  or  eight  milli- 
metres, and  the  epithelium  which  has  become  hard  and  dry  may  be  easily 
removed,  or  in  spots  it  may  be  spontaneously  exfoliated,  leaving  the  ap- 
pearance of  an  ulcer.  The  surface  of  the  patch  is  marked  by  numerous 
fine  lines  or  furrows  which  by  intersecting  each  other  divide  it  into 
small  polygonal  spaces.  Some  of  these  lines  may  extend  as  deep  fissures 
down  through  the  thickened  epithelium,  involving  the  submucous  tissue  in 
a  painful  excoriation.  In  cases  of  long  standing,  the  papilla?  may  be  much 
enlarged,  giving  the  surface  a  warty  appearance,  tinder  the  microscope, 
the  epithelium  is  found  greatly  thickened,  the  papilla?  enlarged  and 
flattened,  and  the  blood  vessels  dilated,  with  an  accumulation  of  leucocytes 
about  their  walls.  The  superficial  layer  of  the.  mucous  corium  is  infil- 
trated with  embryonic  cells,  and  the  deep  layer  is  involved  in  vascular 
alterations. 

Etiology. — Excessive  tobacco  smoking  is  ranked  as  one  of  the  most 
frequent  causes  of  the  disease,  but  it  is  probable  that  prolonged  irrita- 
tion of  any  character  may  have  a  similar  effect  on  those  predisposed  to 
it.  Thus,  highly  spiced  food  and  alcoholics  seem  to  excite  it  in  some  in- 
stances; and  the  occurrence  of  the  affection  in  several  members  of  the 
same  family  led  Bazin  to  believe  that  it  is  often  the  result  of  constitu- 


LEUCOPLAKIA   BUCCALIS.  301 

tional  syphilis.     It  is  also  attributed  to  the  arthritic  or  dartrous  diath- 
esis. 

Symptomatology. — The  clinical  history  of  the  disease  is  not  defi- 
nitely known,  because  generally  it  has  been  discovered  accidentally  and 
found  to  have  existed  for  some  months  or  years  before  it  has  come  under 
the  physician's  observation.  This  is  due  to  the  fact  that  at  first  the 
affection  causes  no  inconvenience.  The  small  patch  which  first  appears 
gradually  increases  in  size  and  at  length  stiffness  occurs  or  painful  fis- 
sures form  which  first  attract  the  -patient's  attention.  Ultimately,  in 
the  majority  of  cases,  epithelioma  results  and  runs  its  usual  course. 
Sometimes  the  affection  remains  stationary  for  months,  or  under  the  in- 
fluence of  some  irritant  it  may  rapidly  progress,  but  it  may  again  become 
dormant  if  the  irritant  is  removed.  Cases  associated  with  syphilis  or 
that  have  developed  into  epithelioma  are  attended  by  much  swelling  of 
the  parts,  and  sometimes  deep  ulceration,  which  may  erode  the  vessels 
and  cause  severe  hemorrhage.  In  these,  the  lymphatic  glands  soon  be- 
come involved,  a  sign  not  observed  in  the  earlier  stages  of  idiopathic 
leucoplakia.  Often  the  first  symptom  is  merely  an  uneasy  sensation, 
but  in  others  the  mucous  membrane  early  becomes  more  or  less  painfully 
sensitive  to  spices,  hot  food  or  drinks,  alcoholics,  or  tobacco.  With  the 
occurrence  of  fissures,  pain  may  become  more  intense  and  almost  con- 
stant, although  in  some  it  is  present  only  at  intervals.  There  are  no 
constitutional  symptoms  until  epithelioma  is  developed.  Late  in  the 
disease,  speaking,  mastication,  and  swallowing  usually  become  difficult, 
especially  when  epithelioma  occurs.  In  such  cases  also  profuse  saliva- 
tion is  often  a  very  annoying  symptom. 

Diagnosis. — Leucoplakia  may  be  misinterpreted  for  what  Guinaud 
has  termed  the  professional  patches  found  in  glass  blowers,  for  smokers' 
patches,  mercurial  patches,  psoriasis  linguas,  syphilitic  patches,  and  epi- 
thelioma unconnected  with  leucoplakia.  The  professional  patches 
occur  only  in  old  glass  blowers,  particularly  bottle-makers,  and  are  found 
symmetrically  upon  both  sides  of  the  mouth,  on  the  lateral  surface  of 
the  gums,  and  around  Steno's  duct.  Smoker's  patches  are  more  irregu- 
lar than  those  of  leucoplakia,  and  are  commonly  located  near  the  com- 
missures of  the  lips,  but  not  upon  the  dorsum  of  the  tongue  or  the  inner 
side  of  the  cheek.  Again,  the  epithelium  covering  their  surfaces  is  thin 
and  closely  adherent,  so  that  it  cannot  be  removed,  as  in  the  disease  un- 
der consideration.  Mercurial  patches  are  not  so  thick  as  those  of  leuco- 
plakia, are  never  quite  white,  and  are  found  on  all  parts  of  the  tongue, 
but  particularly  where  it  is  pressed  against  the  teeth.  In  psoriasis  linguae 
which  sometimes  accompanies  psoriasis  of  the  skin,  the  patches  of  epithe- 
lium assume  a  white,  opaque  appearance  and  after  a  day  or  two  they  are 
thrown  off,  the  epithelium  being  speedily  restored ;  but  soon  other  patches 
appear  and  go  through  a  like  course  until  after  a  time  a  large  part  of  the 
dorsum  of  the  tongue  may  become  denuded  and  of  a  uniform  red  color, 


362  DISEASES   OF  THE  FAUCES. 

with  crescentic  markings  or  depressions  entirely  unlike  the  apjiearance 
of  leucoplakia.  Syphilitic  patches  are  not  bo  white  as  those  of  leucopla- 
kia;  they  are  usually  round  or  oval  and  more  regular  in  form,  seldom 
occurring  on  the  cheek,  but  found  principally  upon  the  tip  or  margin  of 
the  tongue  and  ofteu  on  its  lower  surface,  which  is  never  invaded  by  leu- 
coplakia. The  syphilitic  patches  are  thinner  than  the  patches  of  leuco- 
plakia, and  the  lymphatic  glands  are  much  sooner  involved.  The  pain  is 
more  severe  in  leucoplakia  than  in  the  syphilitic  disease,  and  anti-syphi- 
litic treatment  causes  no  improvement,  but  on  the  contrary  may  aggravate 
the  affection.  "When  syphilis  and  leucoplakia  coexist,  the  diagnosis  is 
difficult.  Cancer  arising  without  previous  leucoplakia  is  distinguished 
from  the  latter  by  its  history;  the  induration  of  the  tissues  and  the  final 
ulceration  are  not  preceded  by  the  chronic  white  patch,  but  are  attended 
by  more  constant  pain,  with  profuse  salivation  and  a  very  offensive 
odor. 

Prognosis. — The  duration  of  the  disease  varies  from  a  few  months 
to  several  years.  The  majority  of  cases  ultimately  terminate  in  epithe- 
lioma, which  runs  its  course  to  a  fatal  issue. 

Treatment. — All  sources  of  irritation,  particularly  the  use  of  tobacco, 
alcoholic  stimulants  and  strong  condiments,  should  be  at  once  removed. 
If  the  digestive  organs  are  deranged,  they  should  receive  proper  attention. 
Aside  from  these  measures,  most  authors  believe  treatment  to  be  of  little 
or  no  avail.  Arsenious  acid,  the  alkalies,  mercury,  and  the  iodides  have 
been  recommended,  though  in  the  absence  of  syphilis  the  latter  seem  to 
be  injurious.  For  local  application  various  caustics,  such  as  silver  nitrate, 
zinc  chloride,  tincture  of  iodine,  and  the  solution  of  mercury  nitrate  have 
been  recommended,  but  none  of  them  seem  of  any  value  except  in  cases 
complicated  by  syphilis.  On  the  contrary,  soothing  applications  seem 
to  have  been  the  most  beneficial,  though  giving  only  temporary  relief. 
I  have  succeeded  in  curing  one  well-marked  case  by  repeated  careful  ap- 
plications of  the  galvano-cautery,  made  to  a  small  spot  at  each  sitting  and 
in  such  manner  as  not  to  destroy  the  healthy  tissue  beneath. 

For  a  more  complete  exposition  of  this  subject  the  student  is  referred  to  my 
paper,  Leucoplakia  Buccalis.  etc..  in  the  Transactions  of  the  American  Laryn- 
gological  Association  for  1885,  page  57. 

ACUTE  TONSILLITIS. 

Synonyms. — Amygdalitis,  cynanche  tonsillaris,  quinsy. 

The  tonsils,  which  are  located  between  the  pillars  of  the  fauces,  are,  in 
the  normal  condition,  scarcely  visible  and  never  large  enough  to  project 
beyond  the  edges  of  the  anterior  pillars.  They  are  essentially  lymphatic 
glands,  but  their  function  is  unknown.  It  is  believed  by  some  that  they 
absorb  a  portion  of  the  starchy  foods,  which  their  secretions  are  capable 
of  converting  into  sugar,  but  this  is  certainly  an  unimportant  function. 


ACUTE  TONSILLITIS.  363 

Upon  the  free  surface  of  these  glands  are  the  orifices  of  from  twelve  to 
eighteen  lacunae  or  crypts  which  are  lined  with  a  continuation  or  pouch 
of  the  mucous  membrane  and  surrounded  by  numerous  spherical  and 
lymphoid  follicles.  These,  together  with  softer  lymphoid  tissue,  consti- 
tute the  substance  of  the  tonsil,  and  are  the  parts  more  or  less  involved 
in  the  disease  under  consideration.  Acute  tonsillitis  is  most  prevalent 
in  humid  climates  and  during  the  spring  and  winter  months.  It  is 
more  frequently  observed  between  the  ages  of  fifteen  and  thirty  years, 
especially  in  subjects  of  the  rheumatic  diathesis.  It  is  peculiarly  prone 
to  attack  those  patients  in  whom  the  tonsils  are  hypertrophied;  and  those 
who  have  once  suffered  from  it  are  liable  to  repeated  attacks.  It  is  only 
occasionally  witnessed  in  young  children  or  the  aged. 

Anatomical  ax'd  Pathological  Characteristics. — The  inflam- 
mation may  attack  the  mucous  membrane  covering  the  surface  of  the 
tonsils,  it  may  be  mainly  confined  to  the  follicles,  or  it  may  involve  the 
whole  substance  of  the  gland,  with  or  without  the  peritonsillar  connec- 
tive tissue.  It  is  frequently  confined  to  one  side,  but  in  many  cases, 
when  the  disease  has  nearly  run  its  course  in  one  gland,  the  other  will 
become  likewise  affected.  The  mucous  membrane  covering  the  tonsil, 
the  pillars  of  the  fauces,  and  a  portion  or  all  of  the  pharynx  is  red  and 
swollen.  The  uvula  is  generally  swollen  and  elongated,  and  is  frequently 
seen  adhering  to  the  affected  tonsil.  In  the  follicular  variety  of  the  dis- 
ease, the  orifices  of  the  crypts  may  become  occluded  and  the  lacuna?  dis- 
tended by  the  changed  secretion,  in  which  event  rupture  may  finally 
occur,  with  a  discharge  of  the  contents,  or,  on  the  other  hand,  the  pent 
up  secretions  may  become  the  centre  of  a  suppurative  process  leading  to 
a  tonsillar  abscess. 

Etiology. — The  disease  is  usually  attributable  to  exposure,  the  rheu- 
matic diathesis,  or  chronic  enlargement  of  the  glands.  Among  the  oc- 
casional causes  of  the  attack  are :  errors  of  diet,  suppression  of  the  menses, 
a  strumous  constitution,  and  heredity.  Higston  Fox  (Transactions  of 
the  Medical  Society  of  London,  Vol.  IX,  p.  255)  believes  that,  where 
both  glands  are  simultaneously  involved,  the  disease  is  almost  invaria- 
bly of  septic  origin.  The  follicular  variety  of  the  disease  is  thought  by 
some  authors  frequently  to  result  from  diphtheria.  This  view,  however, 
does  not  accord  with  the  experience  of  the  great  majority  of  physicians, 
though  undoubtedly  a  few  cases  are  of  diphtheritic  character. 

Symptomatology. — Most  patients  give  a  history  of  previous  similar 
attacks.  The  disease  is  usually  23receded  by  malaise  for  several  hours 
and  attended  by  aching  of  the  back  and  limbs,  and  is  often  ushered 
in  by  a  slight  chill  and  fever.  This  is  speedily  followed  by  sensations 
referable  to  the  throat,  with  swelling  of  the  glands  and  more  or  less 
pain  and  difficulty  in  moving  the  jaw.  In  the  later  stages  of  severe 
cases  there  may  be  great  depression,  cold  perspiration,  insomnia,  rest- 
lessness, and  sometimes  delirium.     The  patients  are  usually  worse  during 


364  DISEASES   OF  THE  FAUCES. 

the  night,  and  experience  most  pain  early  in  the  morning  on  account  of 
the  dryness  of  the  throat.  In  the  inception  of  the  attack  there  are  usu- 
ally sensations  of  dryness  or  pricking  in  the  parts,  soon  followed  by  pain, 
which  is  aggravated  by  deglutition  and  after  a  time  becomes  very  severe, 
even  on  attempts  at  swallowing  the  saliva.  This  pain  is  referred  to  the 
region  surrounding  the  angle  of  the  jaw,  and  radiates  toward  the  ears. 
Occasionally  there  is  severe  headache,  which  is  aggravated  by  movements 
of  the  head.  Owing  to  the  tumefaction,  the  patient  is  frequently  unable 
to  open  his  mouth  more  than  half  an  inch;  partial  deafness  is  common; 
and  the  senses  of  taste  and  smell  are  sometimes  obtunded.  The  face  be- 
comes puffy  and  swollen,  the  skin  hot,  the  pulse  rapid,  and  the  temper- 
ature may  rise  to  103°,  104°  or  105°  F.  A  high  temperature  is  more  to 
be  expected  in  children  or  in  persons  suffering  their' first  attack.  Artic- 
ulation is  difficult  and  enunciation  muffled.  The  swollen  glands  may 
seriously  interfere  with  nasal  and  oral  respiration,  so  much  so  that 
patients  frequently  fear  suffocation,  which  indeed  in  extremely  rare 
cases,  is  an  actual  danger.  There  is  little  or  no  cough,  but  the  patient 
is  frequently  impelled  to  clear  the  throat  of  a  thick,  viscid  secretion 
which  causes  much  discomfort.  The  tongue  is  coated  with  a  yellowish 
white  fur,  while  the  breath  is  very  offensive.  There  is  increased  thirst, 
and  usually  loss  of  appetite.  Even  when  there  is  a  desire  for  food,  the 
patient  can  seldom  take  it  on  account  of  the  painful  deglutition,  while 
attempts  at  swallowing  fluids  oftentimes  result  in  their  regurgitation 
through  the  nose.  The  bowels  are  nearly  always  constipated.  Upon 
examination  of  the  fauces,  the  congestion  and  swelling  of  the  parts  will 
be  readily  distinguished.  It  is  often  desirable  to  make  the  examination 
with  the  aid  of  a  laryngoscopic  reflector,  for  the  patient  is  unable  to 
open  the  mouth  sufficiently  to  permit  a  thorough  inspection  with  ordi- 
nary illumination.  In  the  follicular  type  of  the  disease,  the  orifices  of 
the  crypts  may  be  filled  with  a  yellowish  white  secretion  which  causes 
round  or  oval  patches  from  four  to  eight  millimetres  in  diameter.  In 
exceptional  instances  a  rash  has  been  observed  upon  the  skin. 

Diagnosis. — Acute  tonsillitis  is  to  be  distinguished  from  scarlatina, 
diphtheria,  phlegmonous  tonsillitis,  and  syphilis.  The  essential  points 
in  the  diagnosis  are  the  history,  swelling  of  the  parts,  difficulty  in  open- 
ing the  mouth,  and  severe  pain  on  deglutition. 

In  children,  scarlatina  is  usually  ushered  in  by  vomiting,  which  is 
not  the  case  with  tonsillitis.  The  fever  is  often  higher,  is  always  more 
persistent,  and  after  a  few  hours  a  bright  red  rash  appears  upon  the  sur- 
face of  the  body.  Usually  the  congestion  of  the  fauces  is  much  more 
diffuse  in  scarlatina  than  in  tonsillitis,  and  the  swelling  of  the  parts  is 
much  less.  The  peculiar  appearance  of  the  tongue  in  scarlatina  is  not 
observed  in  tonsillitis. 

Acute  tonsillitis  may  be  distinguished  from  scarlatina  as  follows: 


ACUTE  TONSILLITIS.  365 


Acute  tonsillitis.  Scarlatina. 

Inflammation  and  swelling  of  tonsils.  General    redness    of    fauces,  some- 

But  little  redness  of  pharynx  or  palate.  times  appearing  in  patches,  sometimes 

little  or  no  swelling  of  tonsils. 

Pain  about  angle  of  jaw,  often  re-  Pain,  usually  confined  to  the  throat, 

f erred  to  the  ears.  until  late  in  the  disease. 

Difficult}-  in  opening  the  mouth.  No  difficulty  in  opening  mouth. 

Tongue  coated  yellow.  Strawberry  red  tongue. 

Usually  no  eruption  on  skin.  Characteristic  rash  on  skin. 

The  fever  is  at  first  commonly  lower  in  diphtheria  than  in  tonsillitis, 
there  is  no  difficulty  in  opening  the  mouth,  and  usually  there  is  but  little 
pain.  Upon  examination  of  the  fauces,  there  is  found  a  thick,  grayish 
white  membrane  uniformly  covering  a  large  portion  of  the  throat  or 
confined  to  one  or  two  patches  upon  the  tonsils.  These  patches  are 
much  larger  than  the  yellowish  masses  seen  at  the  orifices  of  the  crypts, 
and  are  less  numerous,  and  they  appear  to  be  laid  upon  the  mucous  mem- 
brane instead  of  being  beneath  it  or  even  with  its  surface.  In  cases  of 
bilateral  follicular  tonsillitis,  the  disease  is  frequently  septic,  and  paraly- 
sis of  the  pharyngeal  muscles  may  follow,  very  closely  simulating  that 
of  diphtheria.  Probably  some  of  these  are  truly  diphtheritic  in  char- 
acter. 

Acute  follicular  tonsillitis  and  diphtheria  present  the  following  dif- 
ferential points  of  diagnosis : 

Acute  follicular  tonsillitis.  Diphtheria. 

Tonsils  inflamed,  enlarged.  Tonsils  not  always  enlarged. 

"Whitish    or    yellowish     deposit     at  Thick,  grayish  white  membrane  on 

orifices  of  crypts.  fauces  or  tonsils,  or  possibly  confined 

to  one  tonsil,  much  larger  than  the 
deposit  of  tonsillitis. 

High  fever.  Oftentimes  subnormal  temperature. 

Difficulty  in  opening  mouth.  No  difficulty  in  opening  mouth. 

Phlegmonous  tonsillitis  is  more  likely  than  acute  tonsillitis,  to  be  con- 
fined to  one  side  of  the  throat.  The  swelling  and  pain  are  greater,  the 
difficulty  of  opening  the  mouth  is  more  pronounced,  and  after  four  or 
five  days  rigors  indicate  the  formation  of  considerable  pus,  while  fluctu- 
ation may  occasionally  be  detected,  especially  if  one  finger  is  placed  on 
the  tonsil  and  the  other  behind  the  angle  of  the  jaw  externally. 

We  can  usually  readily  distinguish  syphilitic  sore  throat  from  acute 
tonsillitis,  but  there  are  cases  in  which  a  diagnosis  is  attended  with 
much  difficulty.  In  specific  sore  throat,  there  is  generally  little  or  no 
fever,  and  ordinarily  but  little  pain ;  the  redness  and  swelling  of  the  parts 
usually  occur  in  symmetrical  patches  upon  both  sides;  and  the  conges- 
tion is  seldom  of  that  bright  red  character  seen  in  tonsillitis.     In  the 


366  DISEASES  OF  THE  FAUCES. 

secondary  disease  superficial  ulceration  and  mucous  patches,  with  possi- 
ble eruptions  upon  the  skin,  and  in  the  tertiary  form,  deep  ulceration  with 
moderate  congestion,  a  peculiar  swelling,  together  with  the  history  and 
other  symptoms,  will  usually  enable  the  physician  to  make  the  diagnosis 
easily. 

From  syphilitic  sore  throat  the  disease  is  distinguished  by  the  fol- 
lowing points  of  difference: 

Acute  tonsillitis.  Syphilitic  sore  throat. 

No  specific  history.     Inflammation  Syphilitic    history.     Comparatively 

and  swelling.     Parts  bright  red.  little  inflammation  or  swelling. 

Often  collection  of  yellowish  secre-  Mucous    patches    usually    symmet- 

tions  in  follicles.  rical. 

High  fever,  acute  pain.  But  little  fever  or  pain. 

Difficulty  in  opening  mouth.  Usually  no  difficulty  in  moving  jaw. 

Prognosis. — There  is  very  little  danger  to  life  from  the  disease,  al- 
though death  has  been  known  to  occur  in  a  few  instances.  The  affection 
often  terminates  in  chronic  hypertrophy  of  the  glands,  and  not  infre- 
quently a  simple  inflammation  eventuates  in  suppuration.  It  is  usually 
the  forerunner  of  other  similar  attacks,  and  is  occasionally  immediately 
preceded  or  followed  by  acute  articular  rheumatism.  It  often  termi- 
nates in  four  or  five  days ;  sometimes,  however,  it  lasts  ten  days  or  two 
weeks,  and  in  exceptional  cases  as  long  as  three  weeks. 

Treatment. — Persons  subject  to  tonsillitis  should  avoid  all  exposure 
likely  to  excite  the  inflammation,  and  should  be  careful  to  keep  the 
digestive  organs  in  perfect  condition,  attending  especially  to  regularity 
of  the  bowels.  Guaiacum  has  been  highly  recommended  for  aborting 
the  disease.  It  is  given  in  the  form  of  troches,  each  containing  two  or 
three  grains,  every  two  hours  during  the  beginning  of  the  attack,  or 
the  ammoniated  tincture  in  doses  of  a  drachm  every  fourth  hour  may 
be  administered  in  milk.  Although  this  remedy  has  the  sanction  of 
high  authority,  I  must  admit  having  seen  very  little,  if  any,  benefit 
from  its  use.  Brushing  the  tonsils  with  a  sixty  grain  solution  of  silver 
nitrate  will  cut  short  the  attack  in  probably  about  one  in  four  cases. 
Aconite,  opium,  and  belladonna  given  in  small  doses,  frequently  repeated, 
have  the  power  of  speedily  abbreviating  the  disease  in  some  instances. 
Aconite  may  be  given  in  doses  of  half  a  minim  of  the  tincture  every  fif- 
teen minutes  until  sweating  or  other  constitutional  effects  are  produced; 
and  thereafter  less  frequently,  about  once  an  hour  for  four  or  five  hours, 
and  still  later  once  in  two,  three,  or  four  hours,  according  to  the  febrile 
symptoms.  The  tincture  of  opium  may  be  given  in  doses  of  one  minim 
every  fifteen  minutes  at  first  until  the  patient  experiences  relief 
from  the  sensations  in  the  throat,  and  subsequently  once  in  from  two  to 
four  hours,  according  to  its  influence  upon  the  pain.  Tincture  of 
belladonna  may  be  given  in  a  similar  way  in  doses  of  a  half-minim.     By 


ACUTE  TONSILLITIS.  367 

some  of  these  measures  the  disease  may  frequently  be  aborted;  but 
it  will  be  found  that  a  remedy  which  acts  well  in  one  person  will  often 
be  entirely  inefficient  in  another.  In  the  beginning,  constipation  should 
be  relieved  by  the  employment  of  a  mercurial  or  saline  cathartic. 

Ice  held  continuously  in  the  mouth,  or  applied  externally  by  means  of 
ice  bags,  will  frequently  check  the  commencing  inflammation.  Fre- 
quent gargling  with  strong  solutions  of  potassium  chlorate  and  nitrate, 
in  water  as  hot  as  can  be  borne,  is  very  beneficial  after  the  disease  is 
fairly  established.  For  this  purpose  it  is  my  custom  to  order  one 
part  of  the  chlorate  and  two  parts  of  the  nitrate,  and  direct  the  patient 
to  use  a  heaping  teaspoonful  of  this  in  half  a  teacup  of  hot  water  every 
half  hour.  Gargling  with  a  one-half  per  cent  to  two  per  cent  solution 
of  carbolic  acid  is  also  useful  in  many  cases.  A  one  per  cent  solution  of 
salicylic  acid  is  also  recommended.  Lemonade  may  be  taken  frequently 
to  clear  the  throat  of  the  tenacious  mucus.  DobelPs  solution  is  also  an 
excellent  mouth  wash  for  this  purpose.  Whenever  there  is  evidence  of 
a  rheumatic  habit,  guaiacum  is  indicated  and  may  be  advantageously 
combined  with  small  doses  of  opium  and  medium  doses  of  the  potassium 
bromide,  which  relieve  the  pain  and  lessen  congestion.  If,  in  spite 
of  these  various  remedies,  the  inflammation  progresses  and  the  tonsils 
become  much  swollen  and  painful,  scarification,  deep  incisions,  or  four 
or  five  simple  junctures  will  often  give  great  relief.  In  making  an  in- 
cision, the  bistoury  should  be  passed  with  its  back  toward  the  outer  por- 
tion of  the  tonsil  and  the  cut  made  toward  the  median  line.  Where  the 
gland  is  very  large,  two  or  three  of  these  cuts  should  be  made.  When 
the  patient  is  subject  to  frequent  attacks  and  the  tonsils  remain  large 
after  the  inflammation  has  subsided,  removal  of  the  glands  should  be 
advised.  There  are  some  patients  who  suffer  from  recurring  attacks  of 
acute  tonsillitis  in  whom  the  glands  subside  after  each  inflammation  so 
that  during  the  period  of  health  they  appear  but  little  if  any  larger  than 
normal.  In  such  cases  it  has  been  recommended  that  the  glands  be  re- 
moved during  the  period  of  an  acute  inflammation,  while  they  are  con- 
siderably enlarged.  The  main  objection  to  this  procedure  is  the  exces- 
sive hemorrhage  which  sometimes  follows.  These  cases  may  be  very 
satisfactorily  treated  by  repeated  punctures  with  the  galvano-cautery.  In 
carrying  out  this  treatment  two  or  three  punctures  should  be  made  at 
each  sitting,  this  not  to  be  repeated  until  two  or  three  days  after  the 
soreness  occasioned  by  the  last  cauterization  has  subsided.  The  treat- 
ment is  necessarily  protracted,  as  ten  or  a  dozen  cauterizations  will  usu- 
ally be  found  necessary.  In  some  of  these  cases  I  have  obtained  excel- 
lent results  by  passing  a  vulsella  forceps  through  the  fenestra  of  the 
tonsillitome,  seizing  the  gland,  drawing  it  well  out,  and  then  cutting  it 
off  with  the  latter  instrument. 


368  DISEA8E8   OF  THE  FAUCES. 

PHLEGMON<  >l*S   T<  >NSILLITI8. 

Synonyins. — Suppurative  tonsillitis,  abscess  of  the  tonsils,  quinsy, 
phlegmonous  sore  throat. 

Phlegmonous  tonsillitis  is  a  suppurative  inflammation  of  the  tonsil 
and  peritonsillar  tissue,  characterized  by  the  formation  of  a  circum- 
scribed abscess.  It  occurs  most  frequently  in  children  or  young  adults; 
seldom  before  the  tenth  year  of  age,  and  not  commonly  after  the  thirtieth 
year.  Persons  who  have  had  it  once  are  much  more  liable  to  attacks 
than  others;  and  those  having  chronic  enlargement  of  the  tonsils  are 
peculiarly  subject  to  this  variety  of  inflammation. 

Anatomical  axo  Pathological  Characteristics. — The  inflam- 
mation attacks  the  mucous  membrane,  the  glandular,  or  the  periton- 
sillar tissue — sometimes  part  and  sometimes  all  of  the  tissues — and  fre- 
quently extends  down  to  the  sheaths  of  the  muscles.  Sometimes  the 
muscles  themselves  are  involved,  but  usually  the  force  of  the  attack  is 
expended  upon  the  connective  tissue  about  the  gland.  The  swelling  is 
nearly  always  unilateral,  and  the  abscess  which  forms  is,  I  think  in  at 
least  four-fifths  of  the  cases,  outside  of  the  gland  itself. 

Etiology. — The  causes  of  the  disease  are  the  same  as  those  of  acute 
tonsillitis,  with  the  addition  usually  of  some  debilitating  circumstance 
which  has  rendered  the  patient  peculiarly  susceptible  to  suppurative  in- 
flammation. 

Symptomatology. — Inquiry  into  the  history  of  such  a  case  frequently 
reveals  that  the  person  has  had  kindred  attacks  several  times  during 
the  previous  two  or  three  years.  The  local  and  constitutional  symp- 
toms in  these  cases  are  essentially  the  same  as  those  of  ordinary  acute 
tonsillitis  of  the  severer  grade.  Superadded  to  these  we  nearly  always 
find  rigors  at  the  time  suppuration  takes  place,  and  sometimes  a  pecul- 
iar, sharp  pain  is  associated  with  the  formation  of  the  abscess.  Swell- 
ing of  the  part  is  excessive,  so  great  in  some  instances,  even  though  con- 
fined to  one  side,  as  to  fill  the  whole  fauces.  As  the  disease  progresses, 
the  spot  at  which  an  opening  is  about  to  take  place  may  be  distinguished. 
This  is  at  first  more  livid  than  the  surrounding  tissue,  and  after  a  time 
it  becomes  yellowish  and  slightly  prominent,  and  finally  the  tissue  gives 
way  and  juts  escapes. 

Diagnosis. — The  disease  is  to  be  differentiated  from  the  same  affec- 
tions that  are  liable  to  be  mistaken  for  acute  tonsillitis.  It  is  not  always 
easy  to  distinguish  it  from  acute  inflammation  of  the  glands  without 
suppuration.  The  essential  points  in  the  diagnosis  are  the  sharp  pain 
and  rigors  at  the  time  of  suppuration,  and  the  occurrence  of  fluctua- 
tion, occasionally  to  be  detected  by  palpation.  However,  in  many  cases 
the  tissues  are  so  tense  that  palpation  will  not  give  distinct  fluctuation 
even  though  considerable  pus  be  present.  Then  an  exploring  needle 
must  be  employed. 


PHLEGMONOUS   TONSILLITIS.  3G9 

Prognosis. — We  expect  suppuration  to  occur  from  the  third  to  the 
sixth  day.  If  the  case  is  left  to  itself,  the  abscess  will  usually  open  spon- 
taneously about  the  tenth  clay,  and  the  patient  will  so  far  recover  as  to 
be  out  of  doors  within  three  or  four  days  after  the  abscess  has  been 
evacuated.  So  far  as  life  is  concerned,  the  prognosis  is  favorable.  There 
have  been,  however,  a  few  exceptions  to  this  rule.  Convalescence  is 
usually  very  rapid,  though  sometimes  the  inflammation  is  followed  by 
some  paralysis  of  the  muscles  of  the  fauces,  which  may  last  several  weeks. 
Paralysis  of  the  palate  causing  indistinctness  of  speech,  and  regurgita- 
tion of  fluids  through  the  nose  when  the  patient  attempts  to  swallow,  is 
the  most  jDrominent  of  these  manifestations.  In  rare  instances  typhoid 
symptoms  supervene  upon  the  acute  inflammation. 

Treatment. — Early  in  the  attack  the  disease  may  be  aborted  as  in 
acute  tonsillitis — in  about  one  case  out  of  four — by  the  application  to  the 
inflamed  gland,  once  or  twice  a  day,  of  a  sixty  grain  solution  of  silver  ni- 
trate, two  or  three  applications  usually  being  sufficient.  If  the  case  is  seen 
early,  I  would  advise  this  treatment,  for,  even  if  it  does  not  succeed,  it  is 
not  harmful.  Care  should  be  exercised  that  none  of  the  solution  drops 
into  the  lower  pharynx  or  the  larynx,  where  it  would  be  likely  to  cause 
spasm  of  the  glottis.  Guaiacum  has  been  highly  recommended  as  a  spe- 
cific for  this  disease,  used  in  the  form  of  troches,  or  the  ammoniated 
tincture  as  already  recommended  for  simple  tonsillitis;  but  it  is  useless  to 
continue  with  it  longer  than  forty-eight  hours.  My  personal  experience 
with  this  remedy  has  been  unsatisfactory;  I  have  never  seen  an  attack 
aborted  by  it,  though  some  have  apparently  been  shortened.  If  abortive 
measures  prove  unavailing,  we  seek  to  conduct  the  inflammation  to  a 
speedy  resolution.  For  this  purpose,  aconite,  opium,  and  anti-rheumatic 
remedies  are  of  chief  value.  Tincture  of  aconite  or  tincture  of  opium 
should  be  given  in  minim  or  half-minim  doses  once  in  fifteen  to  thirty 
minutes  until  the  patient  is  relieved  or  the  constitutional  effects  of  the 
remedy  appear;  afterward  once  an  hour  for  a  few  doses,  and  sub- 
sequently less  frequently  as  the  symptoms  subside.  Ordinarily  eight 
or  ten  doses  must  be  given  close  together,  and  as  many  more  once 
an  hour.  In  most  of  these  cases,  after  the  first  twenty-four  hours, 
sodium  salicylate  gr.  viiss.,  with  potassium  bromide  gr.  x.,  every  fourth 
to  sixth  hour,  are  especially  beneficial.  Local  applications  are  valuable 
in  the  onset  of  the  disease,  ice  being  the  best  remedy.  It  may  be  held 
in  the  throat  constantly,  or  may  be  applied  in  ice  bags  externally,  or  cold 
applications  may  be  made  by  means  of  the  Leiter  coil.  Some  patients, 
however,  are  made  uncomfortable  by  cold;  in  such  we  recommend  gar- 
gling once  an  hour  of  the  solution  hot  as  can  be  of  potassium  nitrate  and 
chlorate,  recommended  for  acute  tonsillitis.  Usually  in  the  first  stage  of 
the  disease  cold  applications  are  to  be  recommended,  and  after  the  second 
day  hot  applications.  Many  of  the  patients  are  constipated;  this  is 
best  overcome  by  saline  cathartics.  Scarification  of  the  tonsils  will 
24 


370  DISEASES   OF  THE  FAUCES. 

sometimes  give  great  relief,  even  before  suppuration  lias  taken  place. 
Pus  should  be  evacuated  us  soon  as  discovered.  Pain  from  the  incisions 
may  be  in  great  part  prevented  by  a  few  applications  of  a  ten  per  cent 
spray  of  cocaine.  Some  patients  think  that  if  the  tonsils  are  cut  they 
are  more  liable  to  subsequent  attacks,  but  there  is  no  foundation  for 
such  belief. 

HYPERTROPHY   OF   THE   TONSILS. 

Synonym. — Chronic  tonsillitis.  This  includes  chronic  follicular  ton- 
sillitis. 

Hypertrophy  of  the  tonsils  is  an  affection  characterized  either  by  a 
collection  of  secretions  in  the  crypts  of  the  gland  and  consequent  irrita- 
tion, with  or  without  hypertrophy  of  the  parenchyma  known  as — chronic 
follicular  tonsillitis,  or  by  simple  hypertrophy  of  the  glandular  tissue  with 
but  little  involvement  of  the  lacuna?.  About  two-thirds  of  the  cases  occur 
in  boys.  It  is  most  frequent  in  youth  or  in  young  adults,  but  it  is  also 
very  common  in  children,  and  is  congenital  in  rare  instances.  The  ten- 
dency to  the  disease  diminishes  with  advancing  years.  The  hypertrophied 
tonsil  presents  a  yellowish-pink  or  dusky  red  color;  it  varies  in  size  from 
a  large  almond  to  a  large  walnut,  and  may  weigh  from  one  to  three 
drachms.  At  times  the  gland  is  very  friable;  again  it  is  firm,  cutting 
with  a  creaking  sound,  owing  to  increase  in  the  connective  tissue.  Some 
of  the  lacuna?  may  be  filled  with  an  extremely  offensive  secretion  of  yel- 
lowish color  and  cheesy  consistency.  When  the  follicles  are  involved, 
with  but  little  hypertrophy  of  the  glandular  tissue,  this  secretion  will  be 
found  in  several  of  them. 

Etiology. — The  disease  is  most  frequently  the  result  of  repeated 
acute  attacks  of  inflammation  of  the  gland,  especially  when  occurring  in 
subjects  of  a  strumous  or  rheumatic  diathesis.  But  the  starting  point 
often  seems  to  have  been  an  attack  of  diphtheria,  scarlatina,  or  measles. 
Again  it  has  also  been  attributed  to  chronic  follicular  pharyngitis  and 
to  acquired  syphilis,  while  occasionally  it  is  supposed  to  be  of  hered- 
itary origin.  The  view  lias  been  advanced  that  follicular  disease  of  the 
tonsil  is  caused  by  bacterial  development  in  the  lacuna?,  but  as  many 
varieties  are  found  in  such  cases  and  as  bacteria  are  always  present  in  de- 
caying organic  substances  and  associated  with  dead  tissue,  their  presence 
here  is  not  sufficient  reason  for  believing  that  they  cause  the  disease. 

Symptomatology. — Sometimes  there  is  the  history  of  a  hereditary 
tendency  to  the  disease,  and  usually  a  history  of  noisy  or  snoring  respira- 
tion with  altered  voice,  and  frequent  acute  attacks  of  tonsillitis.  In 
children  particularly,  partial  deafness  is  a  frequent  symptom.  In 
rare  cases  the  senses  of  smell,  taste,  and  sight  are  said  to  be  affected. 
Pain  is  seldom  present,  except  when  the  lacuna?  become  much  distended 
by  the  secretions,  but  the  patient  often  experiences  more  or  less  dis- 
comfort in  deglutition,  and  sometimes  complains  of  a  sense  as  of  a  for- 


HYPERTROPHY  OF  THE  TONSILS.  371 

eign  body  in  the  throat.  Where  the  glands  are  large,  particularly  in 
children,  the  open  mouth,  dull  eye  and  stupid  appearance  are  almost 
characteristic  of  the  disease.  The  voice  is  usually  thick,  as  though  the 
patient  had  something  in  the  mouth  when  speaking;  it  may  be  husky  or 
hoarse,  or  may  possess  a  guttural  or  nasal  quality.  Some  of  these  patients 
are  easily  fatigued  by  speaking  for  any  length  of  time.  Eespiration  is 
obstructed  in  proportion  to  the  enlargement  of  the  glands.  This  is  more 
especially  noticeable  during  sleep,  when  the  respiratory  movements  are 
often  painful  to  behold.  As  a  result  of  poor  aeration  of  the  blood,  there 
is  frecjuently  great  deterioration  in  the  general  health. 

There  is  but  rarely  actual  danger  of  suffocation,  though  serious  symp- 
toms pointing  in  this  direction  are  occasionally  observed.  Cough  is  not 
usually  present,  but  it  may  sometimes  occur  in  severe  paroxysms.  In 
many  patients  there  is  a  frequent  desire  to  clear  the  throat  of  mucus.  I 
have  seen  children  who  have  coughed  much  at  night,  especially  during 
the  winter,  in  whom  the  cough  has  been  immediately  and  permanently 
relieved  by  removing  the  enlarged  tonsils.  Continued  difficult  breathing 
in  children  may  cause  deformity  of  the  elastic  chest  walls,  which  take 
the  form  of  the  pigeon  breast,  or  the  pyriform  chest  in  which  the  upper 
part  is  prominent  and  the  lower  contracted.  These  distortions  only  oc- 
cur when  the  tonsils  are  extremely  large,  and  possibly  when  the  bony  and 
cartilaginous  structures  are  unusually  soft.  Impairment  of  the  special 
senses  and  the  obstruction  of  respiration  with  its  sequences,  commonly 
attributed  to  hypertrophy  of  the  tonsils,  are  probably  the  result,  in  most 
cases,  of  associated  hypertrophy  of  the  pharyngeal  tonsil.  The  enlarged 
glands  may  sometimes  be  evident  externally,  at  the  angles  of  the  jaw, 
and  occasionally  the  cervical  glands  are  also  enlarged.  Upon  examination 
of  the  throat  the  appearance  of  the  tonsils  already  described  may  be  seen 
at  once. 

Diagnosis. — There  can  be  no  difficulty  in  making  the  diagnosis  if 
the  throat  is  inspected,  except  in  rare  instances  where  the  anterior  pillars 
of  the  fauces  are  adherent  to  the  tonsils  and  hide  them  from  view.  In  such 
cases  the  Occurrence  of  retching  usually  rolls  the  glands  out  so  that  they 
can  be  readily  seen;  but  if  this  does  not  occur,  palpation,  with  one  finger 
on  the  tonsil  and  the  other  externally,  will  readily  detect  the  enlarge- 
ment. 

Prognosis. — The  disease  may  be  expected  to  extend  over  several 
years;  but  when  occurring  in  childhood,  spontaneous  recovery  not  infre- 
quently occurs  at  puberty.  In  young  adults,  the  trouble  usually  subsides 
by  the  thirtieth  year.  There  is  little  danger  from  the  disease  excepting 
that  it  may  impair  the  general  health  or  the  special  senses,  as  already 
indicated.  Persons  with  these  glands  hypertrophied  are  subject  to  fre- 
quent attacks  of  acute  tonsillitis,  and  it  is  probably  a  fact  that  in  them 
the  throat  affections  of  scarlatina  and  diphtheria  are  more  dangerous 
than  in  those  whose  glands  are  normal. 

Treatment. — In  young  children  where  the  glands  are  soft,  the  re- 


372 


DISEASES   OF  THE  FAUCES. 


peated  application  of  powdered  alum  or  other  astringents,  or  the  use  of 
counter  irritation  at  the  angle  of  the  jaw,  or  the  internal  administration 
of  the  syrup  of  the  iodide  of  iron,  or  some  other  preparation  of  iodine, 
will  occasionally  cure  the  disease,  but  this  manner  of  treatment  is  too  un- 
certain to  be  recommended  excepting  where  the  patient  will  tolerate  no 
other.  Enlarged  tonsils  may  sometimes  be  reduced  by  repeated  injections, 
into  the  substance  of  the  gland,  of  iodine,  ergot,  or  carbolic  acid ;  or  by 
electrolysis,  by  the  galvano-cautery,  or  by  cauterization  with  chromic  acid 
or  other  caustics.  The  galvano-cautery  is  especially  useful  in  the  treat- 
ment of  chronic  follicular  tonsillitis.     It  is  highly  recommended  by 


Fig.  94.— Mathieit"s  Tonsillitome  (2-5  size),  with  fenestra  at  right  angles  to  handle. 

C.  H.  Knight,  of  New  York,  and  others  for  reduction  of  hypertrophy  in 
these  glands,  but  it  is  a  tedious  process;  usually  from  ten  to  twenty  or 
thirty  sittings  will  be  required  before  the  desired  end  is  accomplished, 
and  each  of  these  will  cause  but  little  less  discomfort  than  excision,  yet 
the  method  is  to  be  recommended  where  there  is  danger  of  bleeding, 
where  the  disease  is  mainly  confined  to  the  follicles,  and  in  some  cases 
where  the  chronically  inflamed  gland  is  not  sufficiently  large  to  be 
removed  by  other  means.  Electrolysis  may  be  useful  in  some  in- 
stances, but  it  is  tedious  and  not  very  satisfactory.  Enucleation  of 
the  whole  gland  by  the  finger  has  been  recommended,  but  its  ac- 
complishment is  difficult  unless  the  mucous  membrane  has  been  first 


Fig.  95.— The  same  as  Fig.  94,  fenestra  placed  obliquely 

cut  around  at  the  base,  and  even  then  there  is  unnecessary  bruising 
of  the  surrounding  tissues.  In  adults,  the  quickest,  easiest,  and  al- 
together most  satisfactory  procedure  is  removal  by  means  of  the  ton- 
sillitome, which  is  far  preferable  to  the  old  method  by  means  of  the  for- 
ceps and  bistoury,  because  of  the  rapidity  of  the  operation  and  the  small 
danger  of  bleeding.  Many  varieties  of  the  tonsillitome  are  used,  but 
Fahnestock's,  also  known  as  Mathieu's  (Figs.  94  and  95),  has  proved  most 
satisfactory.  It  is  suitable  for  all  cases,  and  will  sometimes  engage  a 
gland  which  cannot  be  secured  by  other  varieties  of  the  instrument.  In 
performing  the  operation,  the  patient  is  to  be  placed  in  a  good  light,  and 
an  assistant  should  make  pressure  behind  the  angle  of  the  jaw  with  the 
finger  so  as  to  crowd  the  gland  well  into  view.  The  operator  should 
then  depress  the  tongue,  encircle  the  tonsil  with  the  ring  of  the  tonsilli- 


HYPERTROPHY  OF  THE  TONSILS.  373 

tome,  press  the  instrument  firmly  down  to  the  base  of  the  gland  and  cut 
it  off  with  a  single  movement.  The  other  may  be  removed  in  the  same 
way  a  few  minutes  later.  The  glands  may  first  be  partially  anesthetized 
by  a  spray  of  cocaine,  but  the  operation  is  not  usually  very  painful 
without  it,  and  cocaine  is  somewhat  objectionable  as  it  tends  to 
increase  the  bleeding,  which  sometimes  comes  on  two  or  three  hours  later. 
It  is  well  to  have  the  patient  use  frequently  a  gargle  of  a  solution  of 
one  and  one-half  per  cent  of  carbolic  acid,  until  the  wound  has  healed. 
Some  recommend  that  only  a  slice  be  removed  from  the  tonsil,  with 
the  hope  that  the  remainder  will  atrophy;  but  the  entire  gland  is  dis- 
eased and,  if  any  considerable  part  of  it  is  allowed  to  remain,  the  patient 
is  almost  sure  to  suffer  from  a  recurrence  of  the  growth,  or  at  least 
from  repeated  attacks  of  acute  inflammation;  therefore  it  is  better, 
when  possible,  that  the  whole  gland  be  removed.  There  are  some  cases 
of  chronic  inflammation  of  the  tonsil  in  which  the  gland  becomes  large 
only  during  the  acute  exacerbations.  These  may  be  treated  by  the 
galvano-cautery  or,  as  recommended  by  Lennox  Browne,  the  gland  may 


Fig.  96.— Ingals'  Tonsil  Forceps  (2-5  size). 

be  removed  during  an  acute  attack  of  inflammation,  notwithstanding  the 
increased  danger  of  hemorrhage.  In  such  cases  I  have  obtained  very 
gratifying  results  by  using  a  vulsella  forceps  and  the  tonsillitome,  as 
indicated  under  acute  tonsillitis. 

In  adults,  as  a  rule,  ecrasement  is  a  less  satisfactory  operation  than 
excision  by  the  tonsillitome;  but  for  young  children  it  is  much  pref- 
erable, because  it  may  be  done  under  the  anaesthetic  influence  of 
chloroform  with  much  less  shock  to  the  friends,  and  with  but  little 
fright  to  the  child,  and  also  because  it  is  nearly  or  completely  blood- 
less. My  method  of  performing  this  operation  is  to  give  the  patient 
chloroform,  place  him  in  the  prone  position,  seize  the  enlarged  gland 
with  the  tonsil  forceps  (Fig.  96)  which  I  have  had  constructed  for 
this  purpose,  and  then  slip  over  the  forceps  and  down  over  the  gland 
the  steel  wire  loop  of  the  snare  which  is  used  for  removing  nasal 
polypi.  As  the  loop  is  drawn  tight,  it  slips  under  the  blades  of  the 
forceps  and  either  cuts  the  gland  close  to  its  base,  or  better  yet,  by  slid- 
ing beneath,  completely  removes  it.  During  the  operation  the  child's 
mouth  is  kept  open  by  a  gag.  I  have  found  it  preferable  to  remove  the 
undermost  gland  while  the  patient  is  lying  upon  one  side  of  the  face, 
then  turning  him  over  to  remove  the  other.  In  seizing  the  gland,  the 
forceps  should  be  carried  back  to  the  pharyngeal  wall,  opened  out,  and 


374  DISEASES  OF  THE  FAUCES. 

then  drawn  forward  until  they  strike  the  anterior  pillar.  At  the  same 
time,  pressure  is  made  externally  behind  the  angle  of  the  jaw,  the  for- 
ceps are  crowded  down,  the  blades  engage  the  upper  and  lower  portion 
of  the  gland,  grasping  it  firmly,  and  the  handles  are  locked.  The  snare 
is  then  slipped  over  the  forceps  and  the  gland  cut  off  and  removed.  This 
may  often  be  done  without  the  loss  of  a  drachm  of  blood.  To  avoid 
removing  the  uvula  at  the  same  time  considerable  care  is  necessary  that 
it  be  not  caught  in  the  forceps  or  snare  with  the  tonsil.  Where  the  an- 
terior pillar  of  the  fauces  is  adherent  to  the  gland  it  should  first  be  sep- 
arated by  a  blunt  hook  and  the  finger.  A  strong  uvula  holder  similar  to 
that  shown  in  Fig.  8-A,  though  less  bent  at  the  hook  and  with  a  larger 
handle,  answers  well  for  this  purpose.  Treatment  of  follicular  tonsillitis  is 
unpromising  by  the  ordinary  methods,  yet  the  disease  may  sometimes  be 
cured  by  inserting  into  the  follicles,  one  after  another  (two  or  three  at 
each  sitting),  a  small  quantity  of  silver  nitrate  or  chromic  acid,  the  re- 
tained secretions  having  first  been  squeezed  out.  Treatment  by  means 
of  the  galvano-cautery  is  usually  very  satisfactory,  and  in  using  this  in- 
strument there  is  no  necessity  of  first  squeezing  the  secretions  out  of  the 
follicles.  I  use  an  electrode  with  a  point  consisting  of  a  loop  of  plati- 
num wire  about  a  centimetre  in  length  by  four  millimetres  in  breadth. 
The  tonsil  is  first  anesthetized  as  well  as  may  be  by  cocaine ;  the  point  is 
then  passed  into  the  diseased  follicle,  heated,  and  moved  about  for  a  second 
so  as  to  touch  its  entire  surface.  Two  or  three  follicles  are  treated  in 
this  way  at  each  sitting,  and  excepting  in  rare  instances  a  few  days  later 
these  points  will  be  found  to  be  completely  cured.  From  five  to  a  dozen 
sittings  may  be  required  to  cure  cases  of  this  kind.  The  treatment 
should  not  be  repeated  for  five  or  six  days;  that  is,  till  two  or  three  days 
after  any  soreness  occasioned  by  the  preceding  cauterization  has  disap- 
peared. 

Excessive  bleeding  is  not  common  after  tonsillotomy,  but  a  few 
cases  of  alarming  hemorrhage  have  occurred,  and  there  is  a  possibil- 
ity of  death  from  this  cause.  Though  the  danger  of  this  is  so  small 
as  hardly  to  merit  consideration,  yet  we  should  always  be  prepared  to 
check  any  undue  hemorrhage  as  speedily  as  possible.  The  methods 
which  have  been  found  most  effective  for  this  purpose  are :  the  sucking 
of  ice,  rubbing  powdered  alum  upon  the  cut  surface,  compression  of  the 
stump  of  the  tonsil  by  the  finger  or  thumb  or  by  means  of  a  sponge 
saturated  with  a  strong  solution  of  tannin  or  of  iron  persulphate,  which 
may  be  applied  by  the  finger,  or  by  one  blade  of  a  pair  of  forceps  the 
other  being  pressed  against  the  external  parts.  Mackenzie  recommended  a 
mixture  of  two  drachms  of  gallic  to  six  of  tannic  acid,  and  enough  water 
to  make  an  ounce,  which  is  to  be  gradually  sipped,  instead  of  being  used 
as  a  gargle.  This  will  prove  efficient  in  nearly  every  case.  In  two 
such  cases  I  have  resorted  to  the  galvano-cautery,  once  with  perfect 
success,  but  in  the  other  1  was    obliged    later  to  use  compression   by 


CONCRETIONS  IN  THE  TONSIL.  375 

means  of  cotton  saturated  with  persulphate  of  iron.  Hot  water  and 
various  other  substances  have  also  been  used  successfully;  but  in 
the  most  severe  hemorrhage  that  ever  occurred  in  my  experience,  after 
all  other  methods  had  failed,  the  bleeding  stopped  as  soon  as. fainting 
occurred,  and  did  not  reappear.  This  harmonizes  with  the  suggestion 
made  by  D.  Bryson  Delavan,  of  New  York,  who  recommends  that  in  ex- 
cessive hemorrhage  after  tonsillotomy  the  limbs  and  arms  be  corded  so 
as  to  retain  as  much  blood  in  them  as  possible,  and  that  fainting  be  en- 
couraged; he  having  observed  that,  in  all  serious  cases,  as  soon  as  this 
took  place  the  bleeding  stopped.  When  advising  removal  of  the  ton- 
sils, we  are  often  asked  as  to  its  probable  effect  upon  the  voice,  and 
occasionally  as  to  its  influence  upon  the  generative  organs.  To  the  first 
we  may  answer  positively  that  it  will  improve  the  voice  if  it  alters  it  in 
any  way;  to  the  second,  we  may  answer  that  there  is  no  reason  for 
believing  that  the  tonsils  have  any  influence  whatever  upon  the  gen- 
erative organs,  though  the  statement  of  Chassaignac  indicates  his  be- 
lief that  hypertrophy  of  the  tonsils  tends  to  arrest  growth  of  these  parts, 
and  removal  of  the  tonsils  favors  their  development. 

CONCRETIONS   IN   THE   TONSIL. 

Synonym. — Calculus  of  the  tonsil. 

Concretions  in  the  tonsil  consist  usually  of  a  collection  in  the  lacuna? 
of  desiccated  secretions  from  the  follicles,  by  which  the  gland  may  be 
much  enlarged  or  inflammation  excited.  Some  of  these  are  hard  and 
others  soft.  The  hard  consist  of  the  phosphate  and  carbonate  of  lime; 
the  soft,  of  the  debris  of  the  epithelial  cells,  cholesterin,  pus  cells,  and 
bacteria,  with  more  or  less  chalk.  This  latter  condition  was  considered 
under  the  head  of  chronic  follicular  tonsillitis. 

Etiology. — The  affection  is  due  to  inflammation  of  the  lacunas. 

Symptomatology. — There  is  usually  a  pricking  sensation  in  the 
tonsil,  with  sometimes  a  little  difficulty  in  swallowing.  The  gland  is 
swollen,  and  upon  inspection  we  find  a  yellowish  white  spot  where  the 
mucous  membrane  is  distended  by  the  mass,  or  some  portion  of  the  cal- 
culus may  be  seen  and  felt  protruding  from  the  surface.  By  touching 
the  mass  with  a  probe,  we  can  readily  determine  whether  it  is  hard  or 
soft. 

Prognosis. — Where  small,  the  concretions  are  frequently  expelled 
spontaneously.  Their  persistence  predisposes  to  hypertrophy  of  the 
tonsils  and  acute  or  phlegmonous  tonsillitis. 

Treatment. — Remove  the  concretion,  and  if  necessary  cauterize  the 
empty  crypt. 


376  DISEASES  OF  THE  FAUCES. 

MYCOSIS  OF  THE  TONSILS. 

Mycosis  of  the  throat  is  a  parasitic  disease  of  the  tonsils  and  upper 
portions  of  the  throat,  characterized  by  yellowish  white  deposits  resem- 
bling in  some  cases  those  of  chronic  follicular  tonsillitis. 

Anatomical  and  Pathological  Characteristics. — The  deposit 
usually  occurs  in  numerous  small,  yellowish  or  yellowish  white  patches 
from  two  to  five  millimetres  in  diameter.  These  are  found  sometimes 
within  the  crypts  of  the  tonsil  or  more  frequently  close  to  their  orifices, 
but  are  not  uncommonly  seen  upon  the  pillars  of  the  fauces  or  the 
pharynx,  and  often  in  considerable  numbers  upon  the  base  of  the 
tongue.  The  deposit  may  in  some  cases  be  so  soft  as  to  be  easily 
scraped  off,  but  in  other  instances  it  is  quite  hard.  Sometimes  it  is  so 
prominent  as  to  become  almost  pedunculated,  and  often  it  presents  a 
papillary  or  warty  appearance.  According  to  Delavan,  scrapings  from 
the  diseased  part,  when  examined  microscopically,  show  the  presence 
of  granular  matter,  pus  corpuscles,  leucocytes,  cholesterin,  and,  most 
important  of  all,  the  leptothrix  buccalis  (Reference  Handbook  of 
Medical  Sciences,  Vol.  VII).  This  organism  attacks  mainly  the  outer 
layers  of  epithelium,  but  sometimes  extends  deeply  into  the  mucosa, 
which  explains  the  difficulty,  in  certain  instances,  of  its  removal  by  swab- 
bing or  scraping. 

Etiology. — The  causes  of  the  affection  are  not  definitely  under- 
stood, but  it  is  said  frequently  to  arise  from  carious  teeth,  where  the 
leptothrix  finds  a  congenial  soil. 

Symptomatology. — Frequently  mycosis  gives  rise  to  no  inconven- 
ience and  is  only  discovered  by  accident;  but  in  other  cases  pricking 
sensations  and  other  symptoms  similar  to  those  of  chronic  follicular  ton- 
sillitis are  experienced. 

Diagnosis. — The  affection  is  liable  to  be  mistaken  for  acute  or 
chronic  follicular  tonsillitis  or  glossitis,  upon  which,  indeed,  it  may  be 
engrafted.  From  the  acute  affections,  it  may  readily  be  distinguished  by 
the  absence  of  congestion  and  swelling  of  the  parts  and  febrile  symp- 
toms, and  by  its  prolonged  course.  From  chronic  follicular  affections 
of  these  parts,  it  is  to  be  distinguished  by  the  position  and  appearance  of 
the  deposits,  and  by  a  microscopic  examination,  which  in  this  disease 
reveals  a  large  number  of  the  micro-organisms  already  referred  to.  The 
deposit  in  mycosis  is  either  soft  or  hard;  and  it  occurs,  as  a  rule,  in  smaller 
masses  than  that  of  chronic  follicular  inflammation;  although  in 
many  cases  it  is  found  within  the  crypts,  on  careful  inspection  it  will  be 
observed  in  some  places  clinging  to  the  surface  of  the  mucous  membrane 
at  the  orifice  of  the  crypts  or  even  remote  from  them.  The  wart  like 
and  sometimes  pedunculated  appearance  which  obtains  with  some  of  the 
masses  is  never  found  in  follicular  tonsillitis  or  glossitis.     The  foreign 


MYCOSIS  OF  THE  TONSILS.  377 

products  are  usually  smaller  and  much  more  numerous  in  mycosis  than 
in  either  of  the  diseases  just  named. 

Mycosis  may  be  differentiated  from  acute  follicular  tonsillitis  as  fol- 
lows: 

Mycosis.  Acute  follicular  tonsillitis. 

No  inflammation  or  swelling.  Inflammation  and  swelling. 

Absence  of  febrile  symptoms.  Fever. 

Prolonged  course.  Brief  history. 

Deposit  soft  or  hard  and  in  small  Collection  of  soft,   yellowish  secre- 

masses;  may  be  found  either  at  orifices  tions  in  the  lacunas. 
of  crypts  or  remote  from  them. 

From  chronic  follicular  tonsillitis,  mycosis  is  to  be  distinguished  by 
the  following  characteristics:' 

Mycosis.  Chronic  follicular  tonsillitis. 

Often  history  of  carious  teeth  only.  Often  history  of  strumous  diathesis, 

or  of  diphtheria,  scarlatina,  or  measles. 

Tonsils  usually  of  normal  size.  Tonsils  usually  enlarged. 

Deposit  in  small  masses ;  found   on  Deposit  within  the  lacunae,  often  in 

mucous  membrane,  and  may  be  remote        large    masses,   not  adherent    to   the 
from  orifices  of  crypts.     They  often        mucous  membrane, 
appear  like  decolorized  warty  growths, 
firmly  attached  to  the  mucous  mem- 
brane and  standing  out  two  or  three 
millimetres  from  the  surface. 

Prognosis. — The  affection,  if  left  to  itself,  is  of  long  continuance, 
and,  if  the  masses  are  scraped  off,  they  tend  to  recur  speedily,  though 
spontaneous  recovery  sometimes  takes  place. 

Treatment. — The  usual  forms  of  treatment  advised  for  chronic 
affections  of  the  throat  have  little  or  no  influence  upon  mycosis,  and,  in 
order  to  eradicate  it,  thorough  and  radical  measures  must  be  adopted. 
Delavan  recommends  frequent  applications  to  the  throat  of  gargles  or 
sprays  containing  either  mercury  bichloride  gr.  i.  ad  3  iv.  or  sodium  bibor- 
ate  gr.  xx.  to  xl.  ad  3  i. ;  but  especially  scraping  off  the  deposit  with  a  sharp 
curette  and  then  applying  the  galvano-cautery  to  the  site  of  the  growth. 
I  have  seen  no  benefit  from  local  applications  of  an  antiseptic,  stim- 
ulant, or  caustic  character,  excepting  the  treatment  by  the  galvano-cau- 
tery which  has  proven  very  efficient,  and  it  has  not  been  found  necessary 
to  scrape  the  part  before  its  application.  Cocaine  is  first  applied,  and 
then  the  masses  are  each  carefully  touched  by  the  galvano-cautery  point, 
four  or  five  being  treated  at  each  sitting,  and  the  process  repeated 
once  in  four  or  five  days  until  all  the  growths  have  been  destroyed. 
There  is  but  little  tendency  to  recurrence  of  any  of  the  masses  which 
have  been  thoroughly  treated  by  the  galvano-cautery.  Carious  teeth 
should,  of  course,  receive  proper  attention. 


378  DISEASES  OF  THE  FAUCES. 

TUBERCULAR  ULCERATION   OF    THE   TOXSILS. 

Tubercular  ulceration  of  the  tonsils  is  extremely  rare  as  a  primary 
lesion,  but  is  not  uncommon  as  a  concomitant  of  advanced  tuberculosis. 

Anatomical  and  Pathological  Characteristics. — Usually  the 
surface  of  the  tonsil  is  pale  and  more  or  less  covered  with  a  viscid, 
yellowish  gray  secretion,  beneath  which  the  tissues  appear  eroded  or 
worm  eaten  by  irregular  superficial  ulcers,  which  may  by  extension 
involve  the  pharyngeal  wall  or  larynx.  The  borders  of  these  superficial 
ulcers  are  not  sharply  defined,  but  irregular,  and  there  is  little  or  no 
swelling  of  the  surrounding  parts.  Sometimes,  however,  the  ulcers  are 
much  deeper,  and  exceptionally  the  edges  may  be  sharp  cut  and  elevated, 
everted,  or  according  to  some  authors  even  undermined,  but  these  latter 
appearances  are  extremely  rare.  Sometimes  the  parts  are  slightly  more 
congested  than  the  surrounding  tissue.  In  the  deep  ulceration  which  I 
have  seen,  the  borders  have  been  clearly  cut,  but  never  undermined  as  in 
syphilis  nor  indurated  as  in  malignant  disease.  The  surface  has  pre- 
sented a  pale,  granulated  appearance,  bleeding  easily  upon  being 
touched.  Microscopical  examinations  of  scrapings  from  the  parts  show  a 
small  amount  of  fibrous  tissue,  epithelial  and  pus  cells,  with  abundance 
of  granular  matter,  and  occasionally  giant  cells,  but  the  bacillus  tuber- 
culosis cannot  often  be  detected. 

Symptomatology. — In  all  the  cases  which  have  come  under  my  ob- 
servation, painful  deglutition  has  been  the  most  prominent  symptom, 
and  in  the  major  number  this  has  been  severe.  Usually,  even  though 
the  tubercular  process  is  slight  in  other  organs,  the  constitutional  symp- 
toms are  very  pronounced.  The  pulse  is  rapid,  the  temperature  rises 
two  or  three  degrees  every  day,  the  strength  fails,  night  sweats  are  com- 
mon, and  the  appetite  is  usually  poor.  Cough  and  expectoration  may, 
however,  be  absent  or  but  slightly  troublesome  if  the  lesion  is  confined 
to  the  faucial  region.  As  the  disease  progresses,  constitutional  symp- 
toms become  more  and  more  marked  and  the  evidences  of  tuberculosis 
in  other  organs  rapidly  develop. 

Diagnosis. — The  disease  may  be  confounded  with  syphilis  or  cancer. 
The  essential  points  in  the  diagnosis  are:  painful  deglutition,  the  con- 
stitutional symptoms,  and  the  comparative  absence  of  induration. 

It  is  distinguished  from  syphilis  by  the  absence  of  a  specific  history, 
bv  the  pain  upon  deglutition,  which  is  usually  much  more  severe  than 
in  syphilitic  ulceration,  and  by  the  pronounced  constitutional  symptoms. 
Again,  when  the  ulcer  is  superficial,  its  worm  eaten  and  irregular  ap- 
pearance, with  the  pallor  of  the  adjacent  surface  and  absence  of  indura- 
tion, are  distinguishing  features;  and  when  the  ulceration  is  deep,  the 
slight  induration,  if  any,  the  irregular  border  of  the  ulcer — neither 
everted  nor  undermined  and  seldom  sharply  cut — and  its  comparatively 


TUBERCULAR   ULCERATION  OF  THE  TONSILS. 


379 


light  color  and  granular,  easily  bleeding  surface,  will  serve  to  distinguish, 
it  from  the  specific  affection.  Anti-syphilitic  treatment,  when  vigorously 
pushed,  usually  causes  rapid  improvement  in  the  specific  disease,  whereas 
it  aggravates  the  tubercular  affection. 

Tubercular  ulceration  of  the  tonsil  is  to  be  distinguished  from  syphili- 
tic ulceration  bv  the  following  characteristics: 


Tubercular  ulceration  of  tonsil. 

Little,  if  any,  swelling'. 

Ulcer  is  usually  superficial,  not 
sharply  defined,  but  may  be  deep  and 
irregular. 

Pain,  fever,  rapid  pulse,  usually  evi- 
dences of  tuberculosis  in  other  organs. 


Syphilitic  ulceration  of  tonsil. 

Syphilitic  history;  induration. 

Ulcer  may  be  superficial  or  deep, 
edges  well  defined,  may  be  undermined 
and  everted:  indurated  base. 

Usually  little  or  no  pain  or  fever, 
with  normal  pulse. 


The  deep  tubercular  ulcer  is  distinguished  from  cancer  of  the  tonsils 
by  the  comparative  absence  of  induration,  which  is  usually  pronounced 
in  cancer  even  for  several  weeks  or  months  before  ulceration  takes 
place;  by  the  appearance  of  the  edges  of  the  ulcer,  which  are  not  everted 
in  tuberculosis,  and  by  the  character  of  the  surface  of  the  ulcer,  which 
is  much  cleaner  in  the  tubercular  disease  than  in  cancer.  The  super- 
ficial ulcer  of  tuberculosis  does  not  resemble  the  ulceration  of  malignant 
disease,  and  is  not  at  all  likely  to  be  confounded  with  it.  Pain  usually 
occurs  earlier  in  cancer  than  in  tuberculosis,  and  is  of  a  lancinating 
character  and  present  for  some  weeks  before  ulceration  takes  place.  In 
the  early  stages,  constitutional  symptoms  are  more  marked  in  tubercu- 
losis than  in  cancer,  and  the  peculiar  cachexia  which  develops  in  the 
later  stages  of  carcinoma  is  not  apparent  in  tuberculosis. 

From  cancer  of  the  tonsil  tubercular  ulceration  may  be  distinguished 
as  follows : 


Tubercular  ulceration  of  tonsil. 

Little,  if  any,  swelling,  with  pallor 
instead  of  congestion  of  parts. 

Usually  ulcer  is  superficial  and  irreg- 
ular, not  sharply  defined;  whitish  se- 
cretions. 

Pain  does  not  occur  until  after  ulcer- 
ation has  commenced,  and  then  is  ex- 
perienced especially  on  swallowing. 

Fever,  rapid  pulse. 

Usually  no  enlargement  of  cervical 
glands. 

Generally  associated  with  pulmo- 
nary tuberculosis 

Prognosis. — "When  the  disease  occurs  primarily  in  the  tonsil,  many 
cases  mav  be  cured  if  taken  early  and  given  thorough  and  energetic 


Cancer  of  the  tonsil. 

Parts  swollen,  indurated,  and  con- 
gested. 

Ulceration  deep  with  abrupt  borders 
and  reddish  or  grayish  white  surface, 
fetid  yellowish  secretions,  and  fungous 
granulations. 

Pain  mai'ked  before,  as  well  as  after, 
ulceration,  and  often  sharp  even  when 
throat  is  at  rest. 

During-  first  few  months  little  if  any 
fever  or  acceleration  of  pulse. 

Enlarged  cervical  glands  compara- 
tively early  in  the  disease. 

Usuallv  marked  cachexia. 


380  DISEASES  OF  THE  FAUCES. 

treatment;  but  when  it  develops  subsequent  to  tuberculosis  in  other 
organs,  little  more  than  temporary  relief  of  the  disease  can  be  hoped  for* 
Treatment. — Where  the  ulceration  is  secondary  to  general  tubercu- 
losis, constitutional  treatment  is  of  the  most  value.  When  the  disease 
is  primary,  destruction  of  the  affected  tissues  by  scraping,  and  the  ap- 
plication of  lactic  acid,  or  the  galvano-cautery  will  occasionally  be  fol- 
lowed by  perfect  recovery.  The  part  should  be  anaesthetized  by  cocaine, 
and  it  may  then  be  scraped  with  the  curette,  and  subsequently  the  lactic 
acid  may  be  applied;  but  some  cases  do  quite  as  well  if  the  acid  is 
thoroughly  applied  without  previous  scraping.  Lactic  acid  is  used  for 
this  purpose  in  strength  varying  from  thirty  per  cent  to  one  hundred 
per  cent,  and  must  be  applied  daily,  and  with  thoroughness,  for  three 
or  four  days,  and  afterward  less  frequently  for  two  or  three  weeks  until 
the  ulcer  heals.  As  a  rule,  when  the  strong  acid  is  employed,  previous 
curetting  is  unnecessary.  If  the  ulcer  is  not  large  and  does  not  readily 
yield  to  the  lactic  acid  treatment,  the  surface  should  be  touched  with 
the  galvano-cautery,  and  subsequently  lactic  acid  may  be  employed. 
For  temporary  relief,  the  parts  may  be  sprayed  with  a  two  to  four  per 
cent  solution  of  cocaine  two  or  three  times  daily,  or,  in  place  of  this, 
with  a  solution  of  morphine,  or,  better  yet,  the  solution  of  morphine, 
carbolic  acid,  and  tannic  acid  (Form.  93)  recommended  for  tubercular 
laryngitis.  Whatever  local  measures  are  adopted,  all  sources  of  irrita- 
tion, especially  tobacco  smoking,  should  be  removed.  Constitutional 
treatment  will  be  of  the  utmost  importance. 

CANCER   OF   THE   TONSIL. 

Cancer  of  the  tonsil  is  a  comparatively  rare  affection ;  but  seven  cases 
have  come  under  my  observation  within  the  last  five  years,  one  being  of 
the  melanotic  variety.  One  or  both  tonsils  may  be  the  seat  of  the  dis- 
ease which  commences  as  a  tumor  in  the  substance  of  the  tonsil  and 
gradually  and  steadily  extends,  involving  not  only  the  whole  gland,  but 
the  surrounding  tissues.  Ulceration  usually  occurs  within  five  or  six 
months  from  the  commencement.  The  affection  is  attended  by  more  or 
less  constant  pain,  especially  upon  deglutition.  This  is  frequently  lan- 
cinating in  character  and  radiates  toward  the  ear.  A  pronounced  cachexia 
is  developed  in  some  instances,  during  the  later  portion  of  the  disease. 

Diagnosis. — Cancer  is  to  be  distinguished  from  hypertrophy  of 
the  tonsil  by  the  history,  age  of  the  patient,  and  course  of  the  dis- 
ease. Hypertrophy  of  the  tonsil  is  a  disease  of  early  life,  seldom  ob- 
served after  the  thirtieth  year,  whereas  cancer  usually  occurs  after  the 
age  of  forty.  Hypertrophy  of  the  tonsil  is  not  attended  by  pain  or 
constitutional  symptoms, and  is  not  followed  by  ulceration;  furthermore 
unlike  the  malignant  disease,  it  may  last  for  years  without  seriously 
affecting  the  patient's  general  health. 


CANCER  OF  THE  TONSIL. 


381 


Cancer  is  to  be  distinguished   from  hypertrophy  of   the  tonsil  as 

follows : 


Cancer  of  tonsil. 

Generally  seen  in  those  past  middle 
life.  Induration  of  surrounding-  tissues 
and  congestion.     Unilateral. 

Late  ulceration  with  reddish  or 
grayish  white  surface,  fetid  secretions, 
fungous  granulations. 

Severe  pain.  Usually  characteristic 
cachexia. 


Hypertrophy  of  tonsil. 

Generally  seen  in  children  and  young 
adults.  Hypertrophy  with  but  little 
if  any  redness.     Generally  bilateral. 

No  ulceration.  Whitish  deposit 
found  in  the  lacunae,  no  peculiar  se- 
cretion. 

No  pain.  Frequently  open  mouth, 
dull  eye,  and  stupid  appearance,  but 
no  cachexia. 


Cancer  of  the  tonsil  and  syphilitic  ulceration  of  the  tonsil  present  the 
following  differential  diagnostic  points: 


Cancer  of  tonsil. 

Much  swelling  and  induration,  mem- 
brane darkly  congested.     Unilateral. 

Late,  ulceration  with  reddish  or 
grayish  white  surface,  profuse  fetid 
secretions  and  fungous  granulations. 

Lancinating  pain, frequently  marked 
before  as  well  as  after  ulceration. 

Usually  marked  cachexia. 


Syphilitic  ulceration  of  tonsil. 

Comparatively  little  swelling  and 
induration.     Usually  bilateral. 

Syphilitic  history.  Ulcer  may  be 
superficial  or  deep  and  undermined 
with  indurated  base  and  everted  edges. 

Little  or  no  pain. 

No  peculiar  cachexia. 


Cancer  of  the  tonsil  is  distinguished  from  tubercular  ulceration  by  the 
signs  pointed  out  in  considering  the  latter  affection. 

Prognosis. — The  disease  usually  runs  its  course  in  four  to  eight 
months,  and  probably  is  always  fatal. 

Treatment. — If  seen  early,  the  tumor  should  be  removed  by  snare  or 
galvano-cautery  ecraseur  if  possible;  or  later,  if  the  growth  is  so  large 
as  seriously  to  interfere  with  respiration  and  deglutition,  a  similar  pro- 
cedure, though  giving  no  hope  of  cure,  may  happily  be  followed  by  devel- 
opment of  the  tumor  in  some  other  direction  less  immediately  dangerous 
or  distressing.  I  have  seen  two  cases  in  which  removal  of  the  cancerous 
tonsil  was  followed  by  perfect  cicatrization  and  no  subsequent  trouble  in 
the  fauces,  whereby  the  patient  was  saved  from  much  of  the  distress 
which  would  otherwise  have  attended  the  later  stage  of  the  disease. 
Recently  I  have  succeeded  in  retarding  the  growth  for  several  months 
by  frequent  injections  into  the  substance  of  the  tumor  of  six  to  ten 
minims  of  a  twenty-five  to  fifty  per  cent  solution  of  lactic  acid. 
After  ulceration  has  taken  place,  surgical  procedures  are  not  likely  to 
be  of  benefit,  but  detergent  and  antiseptic  gargles  and  sprays  may  give 
temporary  relief.  The  spray  of  carbolic  and  tannic  acids  with  morphine 
(Form.  93)  may  be  employed  with  no  little  satisfaction. 


CHAPTEE   XXII 

DISEASES    OF   THE    PHARYNX. 
FOREIGN    BODIES   IN   THE   PHARYNX. 

Foreign  bodies  of  great  variety  have  been  found  lodged  or  impacted 
in  the  pharynx,  the  most  frequent  being  pieces  of  meat,  fragments  of 
bone,  bristles,  false  teeth,  buttons,  coins,  and  needles  or  pins.  Some 
people  in  whom  there  is  impaired  sensibility  of  the  mucous  membrane 
are  specially  predisposed  to  such  lodgements.  Large  bodies  generally 
lodge  at  the  lower  part  of  the  pharynx  or  in  the  valleculas  between  the 
base  of  the  tongue  and  the  epiglottis.  Small  or  sharp  pointed  bodies 
may  become  fixed  at  any  part  of  the  throat,  but  they  are  more  apt  to 
lodge  in  the  crypt  of  a  tonsil  or  in  the  depressions  between  the  gland 
and  the  pillars  of  the  fauces. 

Symptomatology.— Large  bodies,  unless  speedily  removed,  may  cause 
suffocation,  but  this  usually  ensues  only  when  the  substance  has  become 
impacted  in  the  larynx  or  oesophagus.  Hard  or  sharp  substances  cause 
pricking  sensations  or  more  or  less  severe  pain,  especially  on  deglutition, 
and,  if  they  remain,  inflammation  and  swelling  soon  follow.  Even  after 
the  body  has  been  extracted  or  has  passed  into  the  stomach  the  patient 
often  complains  of  similar  sensations  for  some  time.  Ulceration  and 
even  abscess  may  follow  if  the  occluding  substance  remains  for  any 
length  of  time. 

Diagnosis. — The  diagnosis  must  be  based  upon  the  history  given, 
and  a  careful  inspection  of  the  part;  but  it  is  to  be  remembered  that 
sensations  of  pricking  or  actual  pain  are  often  felt  even  after  the  source 
of  the  trouble  has  been  removed.  Hysterical  women  especially,  often 
insist  for  weeks  or  months  that  the  foreign  body  remains,  in  spite  of  all 
assurances  to  the  contrary.  It  is  to  be  remembered  also,  that  small 
bodies  may  actually  remain  for  a  long  time  in  the  crypt  of  a  tonsil,  or  in 
the  valleculas,  escaping  observation. 

Prognosis. — Occasionally  immediate  death  from  suffocation  is  caused 
by  impaction  of  a  foreign  body  in  the  pharynx.  A  fatal  issue  may  like- 
wise result  from  perforation  of  large  arteries  or  other  vital  parts  by 
ulceration,  but  often  the  body  is  either  swallowed  or  expelled  by  the  pa- 
tient's own  efforts.  In  many  instances  these  substances  remain  several 
weeks,  giving  the  patient  much  discomfort  but  not  endangering  life. 

Treatment. — The  foreign  body  should  be  removed  as  soon  as  practi- 


RETRO-PHAR YNGEAL   ABSCESS.  383 

cable.  Unless  seen  at  once,  a  most  thorough  and  painstaking  examina- 
tion should  he  made,  with  the  parts  well  under  the  influence  of  cocaine, 
and  if  nothing  is  found,  a  pledget  of  cotton  should  be  brushed  over 
every  part  with  the  hope  of  removing  or  bringing  into  view  the  possibly- 
hidden  object.  Two  bodies,  especially  in  the  case  of  fish  bones,  are  not 
infrequently  present  in  the  same  case:  therefore  if  the  unusual  sensations 
persist,  another  examination  should  be  made.  As  a  rule,  when  the  sub- 
stance has  been  removed,  the  sensations  disappear  within  a  few  hours, 
but  sometimes  they  continue  for  a  long  time,  usually  as  the  result  of  an 
injury  or  small  ulceration  produced  by  the  object.  Generally  such 
lesions  yield  speedily  to  the  application  of  astringents  or  silver  nitrate. 

RETROPHARYNGEAL   ABSCESS. 

Retro-pharyngeal  abscess,  is  a  circumscribed  suppuration  of  the  sub- 
mucous tissues  of  the  pharynx,  giving  rise  to  swelling,  in  consequence 
of  which  there  is  interference  with  respiration  and  deglutition.  .  The  affec- 
tion occurs  most  frequently  in  infants,  having  been  observed  even  in  the 
new  born:  but  as  a  result  of  syphilis  it  is  comparatively  common  in 
adults. 

Anatomical  axd  Pathological  Characteristics. — The  abscess 
may  be  located  in  the  posterior  wall  of  the  naso-pharynx,  the  oro- 
pharynx, or  the  laryngo-pharynx.  It  may  be  developed  near  the  median 
line,  but  in  about  three  cases  out  of  four  it  is  confined  to  one  side.  The 
loose  attachment  of  the  mucous  membrane  by  cellular  tissue  to  the 
muscles  beneath  favors  the  formation  of  an  abscess  in  this  locality  and 
allows  pus  to  burrow  easily  in  any  direction,  though  it  is  inclined  to 
gravitate  downward.     It  sometimes  extends  even  to  the  mediastinum. 

I  recollect  one  case  in  which  the  sinus,  left  after  the  abscess  had  opened, 
could  be  traced  from  the  lower  part  of  the  oro-pharynx  downward  and  backward 
ten  inches. 

The  tumor  formed  by  an  abscess  has  a  broad  base,  and  the  surface  is 
smooth  and  usually  not  much  discolored,  especially  when  occurring  in 
feeble  children;  though  in  adults  an  abscess  resulting  from  syphilis,  is 
often  considerably  congested. 

Etiology. — The  affection  in  children  is  usually  idiopathic:  yet  if 
the  ultimate  cause  could  be  traced,  it  would  probably  be  found  to  depend 
in  most  instances  upon  an  inherited  scrofulous  or  syphilitic  diathesis. 

The  exciting  cause  is  often  exposure  to  cold  or  to  the  prolonged  heat 
of  summer.  It  may  follow  simple  acute  pharyngitis,  scarlatina,  erysip- 
elas, or  tonsillitis.  In  adults  it  most  commonly  follows  syphilitic  disease 
of  the  cervical  vertebra?.  Some  cases  follow  wounds  inflicted  by  swal- 
lowing pins,  bones,  and  other  foreign  substances.  It  is  said  to  have  fol- 
loAved  stricture  of  the  oesophagus,  owing  to  the  mechanical  irritation  at- 
tending forced  deglutition. 


384  DISEASES   OF  THE  PHARYNX. 

Symptomatology. — The  affection  usually  comes  on  somewhat  slowly, 
being  first  indicated  by  stiffness  of  the  neck,  with  deep  seated  pain, 
which  is  referred  to  the  palate  when  the  abscess  is  far  up,  but  is  com- 
monly felt  deeper  and  may  extend  over  the  entire  throat.  Dyspnoea  and 
dysphagia  generally  arise  from  mechanical  obstruction,  a  result  of  the 
swelling.  In  children,  convulsive  symptoms  often  occur.  According  to 
Bokai,  idiopathic  abscess  may  develop  in  forty-eight  hours,  and  secondary 
abscess  in  from  seven  to  ten  days;  while  that  form  proceeding  from  dis- 
eased bone  is  still  more  chronic  in  its  course.  Primarily,  the  patient 
usually  experiences  slight  chilly  sensations,  but  occasionally  distinct  rigors, 
with  headache  and  slight  rise  of  temperature.  The  pulse  is  usually  weak 
and  compressible,  the  head  is  thrown  backward  or  inclined  to  one  side, 
and  sometimes  there  is  painful  tumefaction  of  the  sides  or  front  of  the 
neck.  If  the  abscess  is  located  in  the  naso-pharynx,  it  interferes  only 
witli  nasal  respiration;  if  in  the  oro-pharynx,  it  does  not  affect  respira- 
tion unless  of  large  size.  If,  however,  the  disease  should  be  situated  in 
the  laryngo-pharynx,  a  comparatively  small  abscess,  by  crowding  the 
mucous  membrane  forward  over  the  larynx,  may  speedily  cause  severe 
dyspnoea  subject  to  frequent  exacerbations  and  accompanied  by  cough 
and  stertorous  breathing.  Abscess  in  the  naso-pharynx  gives  the  voice 
a  nasal  twang,  and  in  the  laryngo-pharynx  may  cause  hoarseness  or  com- 
plete aphonia.  Deglutition  may  be  seriously  disturbed  by  large  abscesses 
in  the  naso-pharynx.  Those  located  in  the  oro-pharynx  or  laryngo- 
pharynx  are  frequently  attended  by  choking  from  the  passage  of  fluids 
into  the  larynx.  Abscesses  in  the  naso-pharynx  may  escajie  observation 
on  inspection,  but  ordinarily  a  dusky  red  tumor  is  visible  which  is  doughy 
to  the  touch,  yet  somewhat  elastic,  but  late  in  the  affection  may  yield 
distinct  fluctuation  and  have  the  appearance  of  pointing. 

Diagnosis. — A  differentiation  is  here  to  be  made  from  croup,  oedema 
of  the  glottis,  foreign  bodies  in  the  larynx,  and  cerebral  or  digestive  dis- 
orders causing  convulsions.  Retro-pharyngeal  abscess  is  distinguished 
from  oedema  of  the  glottis  by  inspection,  which  reveals  the  pharyngeal 
instead  of  laryngeal  swelling;  furthermore,  by  lifting  the  glottis,  the 
dyspnoea  is  relieved  in  an  abscess  situated  very  low,  but  not  in  oedema. 

Retro-pharyngeal  abscess  may  be  diagnosticated  from  oedema  of  the 
glottis  by  the  following  points  of  difference: 

Retko-pharyngeal  abscess.  CEdema  OF  THE   GLOTTIS. 

Pharyngeal  swelling.  Laryngeal  swelling. 

May    be    located   in  oro-pharynx  or  Located  at  glottis, 
]  a  ry  ngo-p  h  ary  n  x . 

Lifting  larynx  relieves  dyspnoea.  Lifting  larynx  does  not  relieve  dysp- 
noea. 

May  interfere  with  nasal  or  obstruct  Does  not  interfere  with  nasal  respira- 

laryngeal  respiration.  tion. 

Rather  insidious  in  its  development.  Conies  on  suddenly. 

Comparative!}'  long  duration.  Short  duration. 


RETRO-PHARYNGEAL   ABSCESS.  365 

Loss  of  voice  or  extreme  hoarseness,  symptoms  not  present  in  retro- 
pharyngeal abscess,  attend  croup/  in  croup  there  is  no  swelling  or 
dysphagia,  both  of  which  are  marked  in  retro-pharyngeal  abscess. 

It  may  be  distinguished  from  foreign  bodies  in  the  larynx  by  the 
history  and  signs  found  by  inspection  and  palpation,  together  with  the 
quality  of  the  voice. 

Between  retro-pharyngeal  abscess  and  foreign  bodies  in  the  larynx, 
the  following  are  the  chief  points  of  difference : 

RETRO  PHARYNGEAL  ABSCESS.  FOREIGN   BODIES  EN  THE  LARYNX. 

Inspection  reveals  a  tumor  in  the  oro-  History  of  accident.     Inspection  and 

pharynx  or  laryngo-pharynx.     Rather        palpation    may     reveal     presence    of 
slow  development.  foreign  body.     Sudden  obstruction  to 

respiration  or  deglutition. 
No  hoarseness.  Voice  usually  much  altered  or  lost. 

It  can  only  be  diagnosed  from  convulsive  disorders  by  a  careful  ex- 
amination of  the  parts  and  detection  of  the  tumor. 

Prognosis. — The  affection  usually  terminates  in  recovery,  idiopathic 
cases  convalescing  in  from  three  to  five  days,  and  secondary  cases  in  from 
seven  to  ten  days,  though  fatal  results  are  not  inf equent.  Abscess  due  to 
spondylitis  may  last  from  three  weeks  to  several  months,  and  usually 
proves  fatal  in  the  end.  In  favorable  cases  the  abscess  opens  spontane- 
ously, unless  sooner  relieved,  and  with  the  escape  of  pus  the  more  violent 
symptoms  at  once  subside.  Pus  may  burrow  into  the  areolar  tissue  of 
the  neck  or  into  the  ary-epiglottic  folds  and  obstruct  respiration  even  to 
suffocation;  or  it  may  escape  into  the  larynx,  with  a  similar  result.  Pus 
burrowing  into  the  mediastinum  may  be  discharged  into  the  oesophagus 
or  pleural  cavity,  an  accident  which  is  serious  iu  either  instance.  Death 
has  been  known  to  result  from  ulceration  of  the  internal  carotid  artery. 

Treatment. — If  the  case  is  seen  early,  the  abscess  may  sometimes 
be  aborted  by  the  continued  sucking  of  ice,  or  by  cold  applications  to  the 
neck.  When  pus  forms,  it  must  be  evacuated  as  soon  as  discovered.  The 
incision  should  be  made  as  near  to  the  median  line  as  possible,  in  order 
to  avoid  injury  to  the  internal  carotid  artery;  and  as  soon  as  the  open- 
ing is  made  the  patient's  head  should  be  thrown  quickly  forward  to  pre- 
vent the  passage  of  pus  into  the  larynx;  or,  better  still,  the  operation 
may  be  done  with  the  patient  lying  upon  the  abdomen,  with  the  face 
extending  slightly  over  the  edge  of  the  table.  An  ordinary  bistoury, 
guarded  to  within  a  quarter  of  an  inch  of  its  point  by  a  wrapping  of 
cloth  or  adhesive  plaster,  is  a  good  instrument  for  the  purpose. 

Tonics  and  supporting  treatment  are  necessary;  the  syrup  of  the 
iodide  of  iron  being  a  most  useful  remedy.  The  phosphates  of  iron  and 
quinine,  or  the  compound  syrup  of  hypophosphites,  may  be  given  with 
benefit.  Cod-liver  oil  is  generally  recommended,  but  should  not  be 
given  unless  it  thoroughly  agrees  with  the  stomach.  In  children  when 
25 


386  DISEASES  OF  THE  PHARYNX. 

there  is  a  tendency  to  convulsions,  potassium  bromide  should  be  admin- 
istered freely  in  the  early  stage. 


TUMORS   OF  THE   PHARYNX. 

Non-malignant  tumors,  especially  of  the  papillary  variety,  are  com- 
paratively frequent  on  the  pillars  of  the  fauces,  tonsils,  or  posterior  wall 
of  the  pharynx.  These  usually  vary  in  size  from  three  to  ten  millime- 
tres in  diameter.  Large  fibrous  (Fig.  97)  and  fatty  tumors  are  also  some- 
times seen.  Small  tumors  cause  but  little  inconvenience,  except  oc- 
casionally a  troublesome  cough  or  sensation  as  of  a  lump  in  the  throat 
during  the  act  of  swallowing.     When  coming  in  contact  with  the  epi- 


Fig.  97.—  Fibroma  of  Laryngo-Pharynx.  This  was  a  large  fibrous  growth  attached  to  the 
lower  portion  of  the  pharynx  by  a  pedicle  about  half  an  inch  in  diameter.  It  was  removed  by  the 
steel  wire  snare  shown  in  speaking  of  nasal  polypi.  The  base  was  subsequently  cauterized  with  the 
galvano-cautery.    No  recurrence. 

glottis  or  larynx,  large  growths  may  interfere  with  respiration  and  deg- 
lutition. 

Treatment. — Small  growths  may  be  readily  removed  by  the  forceps, 
snare,  or  galvano-cautery.  Large  formations,  if  pedunculated,  may  be 
removed  by  the  ordinary  snare,  the  galvano-cautery  ecraseur,  or  ecraseurs 
of  other  forms.  In  cases  of  large  or  vascular  growths,  care  must  be 
taken  not  to  cause  suffocation  during  their  removal,  and  sometimes  pre- 
liminary tracheotomy  may  be  necessary. 


CANCER   OF  THE  PHARYNX. 

Cancer  is  rare  in  the  upper  portion  but  not  so  infrequent  at  the 
lower  part  of  the  pharynx,  where  it  joins  the  oesophagus. 

Anatomical  and  Pathological  Characteristics. — Cancers  of 
the  laryngo-pharynx  usually  first  attack  the  posterior  wall,  and  passing 
around  the  sides  subsequently  invade  the  larynx.  They  are  more  com- 
monly of  the  epitheliomatous  variety,  but  those  of  the  pharyngo-oral 
cavity  are  very  often  of  the  scirrhous  form. 

Symptomatology. — When  the  disease  occurs  in  the  pharyngo-oral 
space,  it  usually  causes  constant  pain,  often  radiating  toward  the  ear,  and 


CANCER   OF  THE  PHARYNX.  387 

is  greatly  aggravated  by  deglutition,  especially  after  ulceration  begins. 
The  voice  is  indistinct,  and  there  is  profuse  fetid  expectoration. 

When  the  tumor  is  situated  in  the  lower  part  of  the  pharynx,  it  is  not 
usually  painful,  although  there  may  be  difficulty  in  swallowing,  and  as 
the  disease  advances  respiration  becomes  embarrassed.  Cancer  at  the 
lower  jDortion  of  the  pharynx  usually  commences  on  the  posterior  wall 
near  the  level  of  the  arytenoid  cartilages,  but  gradually  extends  until 
'it  involves  the  larynx,  causing  tumefaction,  hoarseness,  and  dyspnoea. 

Scirrhous  growth  in  the  upper  pharynx  makes  its  appearance  as  a 
hard,  imperfectly  circumscribed  mass  beneath  the  mucous  membrane, 
which  in  the  early  stages  remains  of  normal  appearance.  As  the  dis- 
ease progresses,  induration  extends  and  may  involve  the  palate,  pillars 
of  the  fauces,  and  even  the  posterior  nares.  Ulceration  follows  and  ex- 
tends over  all  the  affected  tissue,  the  ulcer  presenting  a  reddish  or 
grayish  white  surface  covered  with  fetid  secretion  and  here  and  there 
fungous  granulations.  The  cervical  glands  at  the  angles  of  the  jaw 
are  usually  involved,  comparatively  early  in  the  disease.  Cancer  at  the 
lower  part  of  the  pharynx  usually  appears  first  as  a  grayish  white,  fungous 
vegetation  covered  with  secretion  and  surrounded  by  a  zone  of  red  and 
swollen  mucous  membrane.  As  it  progresses,  extensive  ulceration  may 
occur,  and  all  the  surrounding  tissues  may  become  indurated,  but  tho 
cervical  glands  are  not  usually  much  enlarged. 

Diagnosis. — Cancer  of  the  pharynx  is  not  apt  to  be  mistaken  for 
anything  excepting  syphilitic  disease  or  fibrous  tumors. 

"We  may  generally  readily  distinguish  fibrous  growths  by  their  pedun- 
culated form,  firm  consistence,  and  by  absence  of  pain  and  ulceration. 

As  a  rule,  syphilis  can  be  distinguished  by  the  history,  the  less  amount 
of  pain,  the  presence  of  old  cicatrices,  or  by  the  results  of  medication. 
Under  the  influence  of  j)otassiuni  iodide  given  freely,  the  syphilitic 
patient  usually  increases  in  weight  and  improves  in  general  health, . 
whereas  in  a  person  suffering  from  cancer,  although  this  treatment 
may  appear  to  be  beneficial  for  a  few  days,  the  weight  does  not  increase, 
and  it  is  soon  apparent  that  the  general  condition  is  growing  worse. 

Treatment. — Palliative  measures  only  can  be  adopted.  Opiates,  when 
well  borne,  may  be  given  internally  in  sufficient  quantities  to  relieve 
pain.  The  spray  of  morphine,  carbolic  acid,  and  tannic  acid  (Form.  93) 
will  be  found  beneficial  from  its  property  of  mitigating  the  pain,  modi- 
fying the  offensive  odor  of  the  discharge,  and  exerting  some  restraining 
influence  upon  the  ulceration  or  subjacent  inflammation.  More  than 
this  cannot  be  accomplished  in  the  present  state  of  our  knowledge. 
When  deglutition  becomes  difficult,  food  may  be  administered  per  rec- 
tum or  by  the  oesophageal  tube. 


388  DISEASES  OF  THE  PHARYNX. 

NEUROSES   OF  THE   PHARYNX. 
ANAESTHESIA   OF   THE    PHARYNX. 

Anaesthesia  of  the  pharynx,  a  rare  affection,  is  characterized  by  the 
patient's  inability  to  feel  the  bolus  of  food,  some  portions  of  which  are 
liable  to  remain  in  the  pharynx  and  subsequently  to  be  drawn  into  the 
larynx  during  inspiration. 

Etiology. — Transient  local  anaesthesia  is  produced  by  the  internal 
administration  of  morphine  or  the  bromides  in  large  quantity,  or  by 
local  or  general  anaesthetics.  As  found  in  practice,  tins  affection  is  usually 
a  sequel  of  diphtheria  or  the  result  of  progressive  bulbar  paralysis.  It 
sometimes  occurs  in  hysteria,  and  is  present  in  some  cases  of  typhus 
fever,  cholera,  and  the  general  paralysis  of  the  insane.  It  also  occasion- 
ally attends  epilepsy.  Owing  to  the  liability  of  portions  of  food  to  be 
drawn  into  the  larynx,  patients  come  to  dread  taking  anything  but 
liquids  or  semi-solids. 

Prognosis. — Following  diphtheria,  or  when  associated  with  hysteria 
or  acute  disease,  the  prognosis  is  favorable,  but  in  other  instances  recov- 
ery cannot  be  expected. 

Treatment. — When  well  marked,  food  should  be  given  through  the 
oesophageal  tube.  In  remediable  cases,  tonics  and  galvanism  are  indi- 
cated, but  especially  the  internal  administration  of  strychnine  in  large 
doses.  When  faithfully  followed  out,  promising  results  maybe  expected. 
Strychnine  should  be  given  in  small  but  steadily  increasing  doses  and 
carried  t'o  the  point  of  physiological  toleration  indicated  by  mild  muscu- 
lar spasms.  The  dose  should  then  be  diminished,  but  may  be  again  in- 
creased, after  a  few  days,  to  an  amount  just  short  of  that  which  caused 
the  spasms;  this  dose  may  be  continued  with  benefit  for  days  or  weeks. 

HYPERESTHESIA    OF   THE    PHARYNX. 

Hyperesthesia  of  the  pharynx  is  of  common  occurrence,  but  can 
hardly  be  called  a  disease.  It  is  often  associated  with  acute  inflamma- 
tion of  the  pharynx,  and  is  frequently  found  in  persons  given  to  the 
excessive  use  of  tobacco  or  alcoholic  stimulants.  It  may  be  produced  by 
elongation  of  the  uvula,  and  it  is  one  of  the  manifestations  of  hysteria, 
but  it  is  also  sometimes  present  in  persons  otherwise  in  perfect  health. 
In  marked  cases  the  sensitiveness  may  be  so  great  as  to  interfere  some- 
what with  deglutition  of  solids,  so  that  patients  prefer  to  take  liquid  or 
semi-solid  food;  but  usually  the  condition  causes  no  inconvenience  ex- 
cepting when  the  physician  attempts  to  examine  the  fauces  or  introduce 
the  throat  mirror.  Hyperesthesia  attending  inflammation  may  be  re- 
lieved by  sedative  troches  of  slippery  elm,  althea,  lactucarium,  or  opium. 


PARESTHESIA   OF  THE  PHARYNX.   •  389' 

The  internal  administration  of  from  ten  to  twenty  grain  doses  of  po- 
tassium bromide  three  or  four  times  daily,  and  the  inhalation  from  a 
steam  atomizer  of  a  solution  of  the  same,  gr.  xx.-xxx.  ad  §  i.,  will  also 
be  found  beneficial;  a  five  per  cent  solution  of  carbolic  acid  will  also> 
give  a  good  result,  and  may  sometimes  be  particularly  beneficial  when 
ulceration  is  present.  To  relieve  the  hyperesthesia  which  interferes  with 
laryngoscopic  examination,  the  sucking  of  ice  for  fifteen  or  twenty  min- 
utes will  often  answer  an  excellent  purpose,  but  it  may  usually  be  ac- 
complished more  speedily  by  spraying  the  pharynx  five  or  six  times  with 
a  ten  per  cent  solution  of  cocaine. 

PARESTHESIA    OF    THE    PHARYNX. 

Paraesthesia  of  the  pharynx,  a  common  affection,  is  characterized 
chiefly  by  the  presence  of  sensations  of  heat  or  cold,  pricking,  or  swell- 
ing; or  the  patient  may  imagine  he  feels  in  the  throat  some  foreign  sub- 
stance like  a  hair,  bit  of  straw,  bristle,  or  sliver  of  toothpick. 

Etiology. — The  affection  often  follows  removal  of  foreign  bodies 
from  the  fauces,  but  not  infrequently  it  occurs  in  hysterical  women  with- 
out definite  exciting  causes;  it  is  often  associated  with  a  varicose  condi- 
tion of  the  veins  or  enlargement  of  glands  at  the  base  of  the  tongue,  or  with 
follicular'  pharyngitis.  It  is  sometimes  kept  up  by  a  small  ulcer  which 
may  have  been  caused  by  injury  from  a  foreign  body.  The  principal 
objective  conditions  found  are,  enlargement  of  the  follicles  in  the  phar- 
ynx or  of  the  glands  or  veins  at  the  base  of  the  tongue. 

Prognosis. — The  patient  should  always  be  assured  that  it  is  not  a 
serious  disorder,  for  frequently  he  is  tormented  with  fears  of  cancer ;  but 
he  must  also  be  told  that  the  condition,  in  spite  of  all  treatment,  may 
remain  for  many  months,  though  it  is  likely  eventually  to  subside. 

Treatment. — Enlarged  follicles  upon  the  pharyngeal  wall,  or  enlarged 
glands  or  veins  at  the  base  of  the  tongue,  should  be  destroyed  with  the 
galvano-cautery.  If  this  does  not  relieve  the  sensations,  the  application 
two  or  three  times  daily  of  a  spray  of  morphine,  carbolic  acid,  and  tannic 
acid  (Form.  93),  and  the  internal  administration  of  the  bromides,  with 
nerve  tonics,  is  likely  to  be  most  beneficial.  The  sensations  are  fre- 
quently associated  with  rheumatism ;  under  such  conditions,  anti-rheu- 
matic remedies  should  be  administered. 

Neuralgia  of  the  pharynx  may  be  characterized  by  the  same 
symptoms  as  paresthesia,  but  more  commonly  by  actual  pain.  It  is 
often  due  to  the  same  conditions  as  neuralgia  in  other  portions  of  the 
body  and  frequently  results  from  the  rheumatic  diathesis,  when  it  might 
properly  be  termed  chronic  rheumatic  sore  throat.  The  treatment  con- 
sists of  applications  of  sedative,  astringent,  or  stimulating  sprays  to  the 
throat,  combined  with  the  internal  administration  of  potassium  bromide 
and  nerve  tonics. 


390  DISEASES    OF  THE  PHARYNX. 


SPASM    OF   THE    PHARYNX. 


Spasm  of  the  pharynx  is  a  rare  affection  except  as  associated  with 
acute  inflammation  of  the  fauces  or  hydrophobia,  and  it  is  usually  of 
the  tonic  variety.  The  affection  is  sometimes  associated  with  spasm  of 
the  oesophagus,  and  is  characterized  by  sudden  ejectment  of  fluid  upon 
attempted  deglutition. 

Etiology. — Pharyngeal  spasm  may  be  due  to  acute  pharyngitis, 
tetanus,  hydrophobia,  or  certain  disorders  of  the  brain.  It  is  occasionally 
a  reflex  phenomenon  occurring  in  the  course  of  chronic  pharyngitis,  and 
in  a  mild  form  may  result  from  swallowing  food  which  is  imperfectly 
masticated.     It  may  be  purely  a  neurosis,  asobserved  in  hysterical  persons. 

Symptomatology. — The  spasm  is  marked  by  sudden  ejectment  of 
food  on  attempted  deglutition.  It  may  occur  only  at  certain  times  of 
the  day;  the  patient  perhaps  being  able  to  eat  breakfast  and  dinner 
easily,  but  at  supper  he  may  find  that  he  is  unable  to  swallow.  Some- 
times it  occurs  only  after  taking  certain  kinds  of  food.  It  may  come  at 
the  beginning  of  the  meal,  or  later  after  considerable  food  has  been 
taken;  it  is  always  a  source  of  great  distress  to  both  the  patient  and 
his  friends.  Often,  while  eating  naturally,  the  patient  is  suddenly  com- 
pelled to  rush  from  the  table,  or,  without  warning,  the  food  is  forcibly 
ejected  from  his  mouth. 

Diagnosis. — The  affection  is  to  be  distinguished  from  stricture  or 
paralysis  of  the  oesophagus  and  from  paralysis  of  the  pharynx. 

Solid  or  liquid  foods  are  swallowed  with  more  or  less  difficulty  in 
stricture  of  the  oesophagus;  according  to  the  degree  of  stenosis,  but  the 
bolus  is  not,  as  a  rule,  thrown  out  forcibly,  though  sometimes  this  occurs. 
In  such  cases  persistent  difficulty  in  the  passage  of  an  oesophageal  bougie 
will  settle  the  diagnosis. 

Dysphagia  is  present  in  paralysis  of the  pharynx  or  cesophay  us,  but 
the  food  is  not  suddenly  expelled  from  the  mouth.  In  the  spasmodic 
affection,  according  to  Lennox  Browne  (Diseases  of  the  Throat,  sec- 
ond edition),  an  important  diagnostic  sign  in  protracted  cases  is  ob- 
tained by  placing  the  fingers  over  the  masseter  and  temporal  regions 
during  mastication,  when  it  will  be  found  that  the  muscles  are  more  or 
less  atrophied  from  want  of  use,  a  condition  not  obtained  in  the  disease 
under  consideration. 

Prognosis. — The  affection  may  last  for  weeks  or  months,  and  is 
sometimes  so  serious  a  malady  as  to  necessitate  the  administration  of 
food  per  rectum. 

Treatment. — The  treatment  consists  in  the  administration  of  tonics 
and  nerve  sedatives,  such,  for  example,  as  quinine,  zinc  valerianate, 
arsenious  acid,  potassium  bromide,  camphor  monobromide,  and  asafce- 
tida.  If  associated  with  spasm  of  the  oesophagus,  the  occasional  passage 
of  an  oesophageal  bougie  will  usually  be  found  most  beneficial. 


PARALYSIS    OF  THE  PHARYNX.  391 

PARALYSIS    OF    THE    PHAEIXX. 

Paralysis  of  one  or  more  of  the  constrictor  muscles  of  the  pharynx 
may  be  unilateral  or  bilateral,  partial  or  complete.  It  is  characterized 
by  dysphagia  and  the  accumulation  of  saliva  which  the  patient  is  unable 
to  swallow  and  which  therefore  drips  from  the  mouth. 

Etiology. — The  paralysis  may  be  idiopathic,  but  the  most  common 
cause  is  disease  of  the  medulla  involving  the  origin  of  the  vagus  and 
glosso-pharyngeal  nerves.  It  may  also  result  from  other  cerebral  dis- 
eases. It  sometimes  follows  syphilis,  cerebro-spinal  meningitis,  or  sun- 
stroke, or  accompanies  facial  paralysis,  or  diphtheritic  paralysis  of  the 
oesophagus.  It  sometimes  occurs  in  the  course  of  acute  febrile  diseases, 
and  is  then  commonly  one  of  the  precursors  of  death. 

Symptomatology. — Among  the  most  clearly  characteristic  symptoms 
is  difficulty  of  swallowing,  even  of  the  saliva,  which  constantly  collects 
and  streams  from  the  mouth.  Liquids  also  are  often  taken  with  great 
difficulty  on  account  of  running  into  the  trachea  and  exciting  cough 
and  spasm  of  the  glottis.  This  is  caused  by  associated  paralysis  of  the 
depressors  of  the  epiglottis.  Deglutition  is  generally  accompanied  by 
contortions  of  the  neck  and  face,  from  the  efforts  made  to  assist  the 
passage  of  food.  In  chronic  disease  of  the  brain  and  spinal  cord  these 
symptoms  sometimes  occur  long  before  the  fatal  termination.  In  the 
paralysis  associated  with  facial  paralysis,  the  uvula  usually  deviates 
toward  the  healthy  side,  and  the  palate  scarcely  moves  on  phonation. 
Paralysis  of  the  pharynx  following  diphtheria  usually  comes  on  ten  or 
fifteen  days  after  convalescence  begins,  and  is  characterized  by  dysphagia, 
especially  on  attempts  to  swallow  fluid,  inability  to  expectorate,  and  a 
peculiar  nasal  timbre  of  the  voice  due  to  paresis  of  the  palate,  with  non- 
closure of  the  passage  to  the  naso-pharynx.  The  sense  of  taste  is  ob- 
tunded,  and  the  velum  is  usually  relaxed  upon  one  side.  Paralysis  of 
the  pharynx  is  frequently  associated  with  paresis  of  the  oesophagus, 
in  which  condition  solids  are  swallowed  more  easily  than  fluids,  and  large 
boluses  than  small. 

Paralysis  of  the  pharynx  is  often  one  of  the  early  symptoms  of  pro- 
gressive bulbar  paralysis.  In  this  affection  loss  of  motion  is  usually  first 
manifested  in  the  tongue,  lips,  and  palate,  causing  at  first  indistinctness 
and  slowness  of  speech,  but  later,  difficulty  in  mastication  and  finally 
dysphagia,  with  more  or  less  dyspnoea  due  to  spasm  of  the  glottis  caused 
by  entrance  into  the  larynx  of  liquid  or  solid  food.  The  voice  is  weak 
and  often  aphonic,  and  there  is  inability  to  pronounce  the  labials  b, 
w,  m,  p,  or  the  dentals  f,  d,  v,  n,  and  th. 

Diagnosis. — The  diagnosis  depends  upon  the  history,  symptoms,  and 
signs  just  described.  The  continuous  character  of  the  paralysis  distin- 
guishes it  from  spasm  of  the  pharynx. 

Prognosis. — When  due  to  temporary  causes,  when  following  diph- 


392  DISEASES  OF  THE  PHARYNX. 

theria  or  other  acute  diseases,  or  when  associated  with  facial  paralysis, 
recovery  may  be  expected;  but  cases  dependent  upon  progressive  bulbar 
rjaralysis  always  end  in  death. 

Treatment. — If  food  cannot  be  swallowed,  it  must  be  administered 
by  means  of  the  oesophageal  tube  or  per  rectum.  Internally  iron,  qui- 
nine, arsenious  acid  and  strychnine,  especially  the  hitter,  are  indicated 
in  most  cases,  and  sometimes  considerable  benefit  will  be  obtained  by 
change  of  air  and  scene.  Here,  as  in  anaesthesia  of  the  pharynx,  the  most 
pronounced  benefit  will  usually  be  obtained  from  strychnine,  in  large  and 
gradually  increasing  doses. 

SCALDS   AND   BURNS   OF  THE   PHARYNX. 

Injuries  by  heat  are  not  uncommon,  especially  among  children  of 
the  poor,  in  whom  they  frequently  follow  inhalation  of  steam  from  the 
teapot.  They  are  sometimes  caused  in  adults,  by  the  inhalation  of  steam, 
flame,  or  hot  air,  as  in  burning  vessels  or  buildings.  In  such  cases  the 
tongue,  palate,  and  often  the  nares  and  oesophagus  are  similarly  affected. 

Symptomatology. — There  is  acute  pain  and  distress  in  the  throat, 
with  quickened  pulse  and  more  or  less  fever.  Usually  the  larynx  is  in- 
volved, and  swelling  and  dyspnoea  are  speedy  results.  Cohen  states  that 
when  smoke  has  been  inhaled,  the  sputum  is  blackish  in  color  for  several 
days  ("  Diseases  of  the  Throat ").     Dysphagia  is  always  present. 

If  seen  early,  the  affected  parts  are  of  a  whitish  color  due  to  burning 
of  the  mucous  membrane,  and  shortly  afterward  patches  of  the  mem- 
brane are  found  to  be  destroyed,  and  severe  inflammation  with  marked 
swelling  ensues. 

Diagnosis. — The  diagnosis  may  be  easily  made  from  the  history, 
symptoms,  and  appearance  of  the  parts. 

Prognosis. — In  many  instances  the  accident  is  speedily  fatal,  and  in 
all  cases  where  the  burn  is  at  all  severe  the  prognosis  is  very  grave.  If 
the  patient  lives  long  enough,  sloughing  and  excessive  suppuration  occur, 
and  vicious  adhesions,  together  with  chronic  laryngitis  and  stenosis  of 
the  larynx  and  trachea,  are  apt  to  follow. 

Treatment. — Cold  compresses,  with  sucking  of  ice  and  soothing  ap- 
plications, should  be  employed,  mucilaginous  drinks  being  given  if  they 
can  be  swallowed.  Nourishment  must  be  given  by  enemata,  when 
deglutition  is  impossible.  If  dyspnoea  supervene,  tracheotomy  must 
be  promptly  performed  to  prevent  suffocation.  Unfortunately,  how- 
ever,  in  these  cases  the  operation  does  not  often  prevent  a  fatal  issue. 

SWALLOWING  THE  TONGUE. 

The  so  called  swallowing  the  tongue  is  an  extremely  rare  accident. 
Most  of  the  cases  recorded  seem  to  have  occurred  in  children  suffering 
from   whooping  cough.     A   case  which   I   reported   to   the    American 


DISEASES  OF  THE  VALLECULAS  AND  PYRIFORM  SINUSES.     393 

Laryngological  Society  at  its  annual  meeting,  1880,  occurred  in  a  lady 
suffering  from  hysteria.  It  was  characterized  by  a  spasmodic  action  of 
the  hyo-glossus  and  probably  also  the  stylo-glossus  muscles,  which  drew 
the  tongue  into  the  pharynx  in  such  a  position  as  to  prevent  respiration. 
There  was  no  cough.     The  accident  may  prove  speedily  fatal. 

Teeatment. — The  tongue  should  at  once  be  drawn  forward  to  pre- 
vent suffocation.  Subsequently  the  primary  disease  should  receive  ap- 
propriate treatment. 

DISEASES  OP  THE  VALLECULA  AND  PYRIFORM  SINUSES. 

Ulceration  of  the  vallecula?  at  the  base  of  the  tongue,  or  of  the  pyri- 
form  sinuses  of  the  larynx,  occasionally  occurs  from  injury  in  swallowing 
bits  of  bone  or  food,  and  sometimes  from  inflammation  of  the  glandular 
structure.  Ulcers  in  either  position  give  rise  to  pricking  sensations  and 
pain  upon  deglutition,  and  those  in  the  pyriform  sinuses  are  attended 
also  by  cough.  Upon  inspection  with  the  laryngoscope,  the  vallecula© 
are  commonly  found  filled  with  secretions,  which  must  be  wiped  away 
before  the  cause  of  the  trouble  can  be  discovered,  and  it  is  usually  nec- 
essary to  anaesthetize  the  parts  thoroughly  with  cocaine  in  order  to  make 
a  complete  examination. 

Teeatment. — If  foreign  bodies  are  found,  their  removal  usually  gives 
prompt  relief.  If  ulcers  exist,  they  are  generally  speedily  cured  by 
touching  them  once  or  twice  with  a  solution  of  silver  nitrate,  gr.  lx.  ad  §  i. 


CHAPTER   XXIII. 

DISEASES    OF    THE    LARYNX. 
ACUTE   LARYNGITIS. 

Synonyms, — Acute  catarrhal  laryngitis,  cynancke  Liryngea,  angina 
laryngea,  angina  epiglottidea,  inilammation  of  the  larynx. 

Acute  laryngitis  is  a  simple  catarrhal  inflammation  of  the  mucous 
membrane  of  the  larynx,  characterized  by  pain*  dyspnoea*  dysphonia  or 
aphonia,  stridulous  breathing,  and  cough. 

Anatomical  axd  Pathological  Charaoj  eristics. — In  mild  cases 
there  is  congestion  with  slight  swelling  of  the  mucous  membrane,  either 
uniformly  or  in  patches;  the  latter  are  more  commonly  found  at  the 
posterior  end  of  the  vocal  cords,  the  posterior  commissure,  or  on  the  ven- 
tricular band.  In  more  severe  cases  the  mucous  membrane  is  cedema- 
tous  and  deeply  congested,  the  epiglottis  is  thickened  and  flaccid,  the 
ary-epiglottic  folds  are  swollen  into  thick,  pyriform  bodies,  and  the  ven- 
tricular bands  may  be  so  swollen  as  to  overlap  and  completely  hide  the 
cords. 

Etiology. — Indoor  occupation,  malnutrition  or  defective  excretion, 
and  excessive  use  of  alcoholic  stimulants  or  tobacco,  are  among  the 
principal  predisposing  causes.  Certain  diseases,  as  measles,  scarlatina, 
and  variola,  also  favor  its  occurrence.  Among  the  exciting  causes  are 
exposure  to  irritating  vapors  or  drugs,  to  wet  and  cold,  or  to  draughts 
of  air,  also  violent  cough  and  excessive  use  of  the  voice,  especially  in  the 
open  air.  It  is  also  frequently  due  to  extension  of  inflammation  from 
the  neighboring  mucous  membrane. 

Symptomatology. — The  affection  usually  comes  on  insidiously,  pre- 
ceded by  a  mild  rhinitis,  pharyngitis,  or  bronchitis,  and  is  finally  ushered 
in  by  slight  rigors  or  chilly  sensations.  In  severe  cases  there  is  some- 
times a  pronounced  chill  followed  by  rapid  development  of  the  symptoms. 
Sensations  of  dryness,  roughness,  or  tickling  in  the  larynx  are  early  ex- 
perienced, and  these  may  be  followed  by  pain,  which  is  aggravated  by 
coughing  or  speaking.  As  the  disease  progresses,  there  is  a  feeling  of 
constriction,  the  tendency  to  cough  and  clear  the  throat  becomes  more 
pronounced,  and  the  swelling  may  give  rise  to  sensation  as  of  a  foreign 
body.  The  pain  is  aggravated  by  deglutition,  and  tenderness  is  usually 
elicited  by  palpation.  At  first  respiration  is  not  affected,  but  as  soon  as 
swelling  occurs   dyspnoea  comes  on,  and  in  severe  cases  becomes  very 


ACUTE  LARYNGITIS.  395 

distressing.  The  patient  cannot  lie  down,  is  very  restless  and  makes 
frantic  efforts  for  breath.  At  the  commencement  of  the  attack,  the  face 
is  flushed  and  the  eyes  are  bright,  but,  as  dyspnoea  develops,  the  face 
becomes  livid  and  anxious,  or  of  an  ashy  hue,  and  the  eyes  protrude  as 
in  strangulation.  The  skin,  which  is  at  first  hot,  particularly  in  chil- 
dren, becomes  cold  and  clammy;  the  pulse,  at  first  full  and  bounding, 
grows  weak  and  irregular,  and. the  temperature  rises  to  102°,  103°,  or 
104°  F.  The  voice,  in  the  beginning  hoarse  and  shrill,  later  may  be  weak 
or  entirely  lost.  The  cough,  at  first  resonant  and  clear,  becomes  convul- 
sive, brazen  or  croupy  in  character,  and  there  is  a  slight  expectoration  of 
tenacious,  glairy  mucus  until  toward  the  end  of  the  disease,  when  the  secre- 
tions become  muco-purulent  in  character,  and  profuse  when  the  bronchi 
are  also  involved.  Children  suffering  from  acute  laryngitis  are  prone  to 
croupy  attacks  at  night,  probably  due  to  the  collection  of  secretions 
about  the  glottis.     The  tongue  is  usually  white,  furred,  and  red  at  the 


Fig.  98.— Superficial  Ulcers  op  Vocal  Cords.  Fig.  99.— Superficial  Ulceration  of  Epi- 

Herpetic ;  covered  with  a  thin  whitish  false  glottis.  Herpetic ;  covered  with  a  thin 
membrane.  whitish  false  membrane. 

tip.  Upon  laryngoscopic  examination,  the  congestion  and  swelling  are 
readily  detected,  and  occasionally  small  erosions,  particularly  at  the  vocal 
processes,  are  observed.  In  rare  instances,  superficial  ulcerations  of  an 
herpetic  character  are  seen,  though  these  are  not  apt  to  be  associated 
with  much  congestion  and  swelling  of  the  parts  (Figs.  98  and  99).  As 
a  result  of  the  swelling,  there  is  frequently  paresis  of  the  arytenoideus  or 
of  the  thyro-arytenoid  muscles,  giving  rise  to  the  gaping  of  the  cords 
(Figs.  182, 183).  Occasionally,  even  before  hyperemia  occurs,  the  patient 
becomes  hoarse,  and  upon  examination  paresis  is  found  to  be  present. 

A  mild  form  of  laryngitis  frequently  attends  asthma  or  hay  fever. 

Diagnosis. — The  disease  is  to  be  distinguished  from  laryngismus 
stridulus,  true  croup,  paralysis  of  the  vocal  cords,  and  foreign  bodies  in 
the  larynx.  The  chief  features  in  the  diagnosis  are  hoarseness  and 
dryness  and  pain  in  the  larynx,  with  hyperaemia  and  swelling.  It  is  dis- 
tinguished from  laryngismus  stridulus  by  coming,  on  more  slowly  and 
being  attended  by  chills,  fever,  congestion,  and  swelling  of  the  parts. 

The  following  are  the  differential  points  peculiar  to  acute  laryn- 
gitis and  laryngismus  stridulus ; 


39b  DISEASES   OF  THE  LARYNX. 

Acute  laryngitis.  Laryngismus  stridulus. 

Congestion  and  swelling'  of  mucous  No  congestion  or  swelling  of  mucous 

membrane.  membrane. 

Fever.  No  fever. 

Generally  pain.  No  pain. 

Gradual    accession,  and  of    several  Sudden  in  its  onset    and  short  in 

days  duration.  duration.     Attack  usually    at    night; 

may  not  be  repeated. 

It  is  distinguished  from  true  croup  by  the  age  of  the  patient  and  by  the 
greater  amount  of  pain,  congestion,  and  swelling;  by  the  scanty  tenacious 
sputum  and  absence  of  false  membrane.  When  occurring  in  young  chil- 
dren, it  is  not  always  possible  to  make  an  accurate  diagnosis. 

Acute  laryngitis  is  distinguished  from  paralysis  of  the  vara!  curds,  by 
the  pain,  congestion,  and  swelling,  which  are  not  present  in  the  latter 
disease;  and  by  the  other  points  presented  in  the  following  table: 

Acute  laryngitis.  Paralysis  of  the  vocal  cords. 

Pain,  congestion,  and  swelling.  Entire  absence  of  pain,  congestion, 

and  swelling. 
Voice  harsh;  sometimes  aphonia  for  Aphonia  pronounced,   especially    if 

a  brief  period.  patient  is  fatigued;  is  present  through- 

out course  of  disease. 
Short  duration.  Long  duration. 

It  is  to  be  differentiated  from  foreign  bodies  in  the  larynx  by  the 
history  and  by  laryngoscopic  examination. 

Prognosis. — Mild  cases  usually  pass  off  in  four  or  five  days,  and 
others  in  most  instances  soon  yield  to  suitable  remedies;  but  occasion- 
ally the  swelling  and  consequent  obstruction  of  the  glottis  are  so  great 
as  to  cause  death.  Neglected  cases,  or  those  in  which  the  patient  again 
exposes  himself  before  the  inflammation  has  entirely  subsided,  are  liable 
to  end  in  chronic  laryngitis. 

Treatment. — Cold  compresses  renewed  every  half-hour  or  hour  are 
found  most  effective  in  the  beginning  of  the  disease.  If  these  fail,  seda- 
tive vapors  or  inhalations  of  steam  impregnated  with  opium,  belladonna, 
or  lupulin  (Form.  55,  56,  57),  together  with  large  doses  of  potassium 
bromide  and  warm  compresses,  will  be  found  more  effective.  The  dis- 
ease is  sometimes  aborted  by  the  early  administration  of  ten  grain  doses 
of  Dover's  powder  or  quinine,  or  small  and  frequently  repeated  doses  of 
the  tincture  of  aconite  or  opium,  one  minim  every  half-hour  or  hour  for 
ten  or  twelve  hours,  or  until  the  physiological  effects  are  obtained,  and 
subsequently  less  often.  Saline  cathartics  to  keep  the  bowels  open  are 
usually  desirable  unless  the  affection  is  aborted  within  twenty-four 
hours.  In  all  cases  in  any  degree  severe,  the  patient  should  remain  in 
the  house  in  a  warm,  moist  atmosphere,  and  refrain  from  using  the 
voice.  Toward  the  close  of  the  disease,  the  application  of  mild  astrin- 
gent sprays  (Form.  88,  90,  94)  once  or  twice  daily  will  be  found  very 


SUBACUTE  LARYNGITIS.  397 

beneficial.  Sometimes  compressed  tablets  of  potassium  chlorate  are  also 
useful.  If  oedema  occurs  so  as  seriously  to  impede  the  respiration,  scar- 
ification or  rupture  of  the  swollen  membrane  is  indicated,  though  the 
necessity  for  it  may  sometimes  be  removed  by  administration  of  the 
fluid  extract  of  jaborandi,  or  its  active  principle  pilocarpine,  in  sufficient 
quantity  to  excite  profuse  diaphoresis  and  salivation.  Scarification  is 
best  practised  by  means  of  the  guarded  laryngeal  lancet  (Fig.  100).  The 
mucous  membrane  may  sometimes  be  ruptured  by  the  finger  nail,  the 
edge  of  which  has  been  roughened  for  the  purpose.  Severe  cases  may 
require  intubation  or  tracheotomy.  In  children  where  there  is  doubt  as 
to  the  diagnosis,  the  disease  should  be  managed  in  the  same  way  as  true 


Fig.  100.— Mackenzie's  Laryngeal  Lancet  (3-5  ordinary  size). 

croup.  It  is  generally  best  in  the  beginning  to  give  a  free  calomel 
purge  and  follow  this  by  the  treatment  suitable  for  true  croup,  intuba- 
tion or  tracheotomy  being  performed  as  soon  as  there  is  serious  inter- 
ference with  respiration. 

SUBACUTE   LARYN&ITIS. 

Subacute  laryngitis  is  a  mild  form,  usually  present  in  what  is  known 
as  an  ordinary  cold.  It  is  characterized  by  dryness  or  tickling  sensa- 
tions in  the  larynx,  with  slight  pain,  hoarseness,  and  inclination  to  cough, 
with  but  little  or  no  fever.  The  cough  is  laryngeal,  hacking,  and 
more  or  less  paroxysmal,  and  the  expectoration  usually  consists  of  a  small 
amount  of  clear,  tenacious  mucus.  The  causes  are  the  same  as  those  of 
acute  laryngitis,  operating  in  a  milder  degree.  Upon  inspection  of  the 
larynx,  more  or  less  congestion  is  observed,  but  frequently  none  except 
along  the  edges  of  the  vocal  cords  at  their  posterior  extremities. 

Prognosis. — The  prognosis  is  favorable,  and  often  the  only  treat- 
ment needed  is  care  as  to  exposure,  and  confinement  to  the  house  for  one 
or  two  days.  Even  this  precaution  is  neglected  by  most  patients,  yet  the 
great  majority  recover  within  five  or  ten  days. 

Treatment. — Local  and  internal  treatment  suitable  for  mild  cases  of 
acute  laryngitis  are  appropriate  in  the  subacute  form,  and  mild  astrin- 


398  1>LS  EASES   OF  THE  LARYNX. 

gent  sprays  are  especially  indicated  in  the  latter  portion  of  the  attack  if  the 
patient  suffers  from  hoarseness,  tickling  in  the  larynx,  or  a  tendency  to 
cough.  Unless  the  patient  is  careful  not  again  to  expose  himself,  there 
is  great  liability  to  recurrence  of  the  attack,  and,  if  this  is  repeated  a  few 
times,  chronic  laryngitis  is  the  probable  sequel. 

TRAUMATIC    LARYNGITIS. 

Traumatic  laryngitis  may  result  from  the  irritation  caused  by  foreign 
bodies,  from  the  inhalation  of  irritating  gases,  or  from  mechanical  injury 
in  operations;  but  most  commonly  it  occurs  in  children  from  swallowing 
boiling  liquids,  strong  acids  or  alkalies,  or  inhaling  steam,  as,  for  exam- 
ple, in  attempting  to  drink  from  a  tea-kettle. 

Symptomatology. — After  the  accident  causing  it,  the  inflammation 
comes  on  almost  instantaneously,  with  acute  pain,  and  oedema  of  the 
epiglottis  and  deeper  portions  of  the  larynx  which  causes  great  dyspnoea. 
The  tongue  and  throat  are  red  and  angry,  or  white  from  detachment  of 
the  epithelial  layer  of  the  mucous  membrane  or  from  plastic  exudation. 
The  ©edematous  epiglottis  can  often  be  seen  without  the  aid  of  the 
laryngoscope,  standing  up  behind  the  base  of  the  tongue.  It  is  seldom 
possible  to  make  a  laryngoscopic  examination. 

Diagnosis. — The  diagnosis  will  be  easily  made  from  the  history,  and 
from  the  appearance  of  the  mouth  and  fauces. 

Prognosis. — The  prognosis  depends  upon  the  extent  of  the  injury, 
but  is  commonly  grave,  especially  when  the  disease  results  from  scalds  or 
burns. 

Treatment. — The  affection  can  sometimes  be  aborted  by  painting 
the  parts  with  a  strong  solution  of  silver  nitrate.  However,  this  appli- 
cation is  not  devoid  of  danger  from  spasm  of  the  glottis.  Full  doses  of 
jaborandi  may  be  tried.  Constant  applications  of  ice  to  the  neck,  and 
the  sucking  of  ice,  should  be  practised;  or,  in  its  stead,  hot  applications 
or  inhalations  of  steam.  The  parts  usually  become  ©edematous  in  spite 
of  these  measures,  and  then  scarification  or  tracheotomy  must  be  prompt- 
ly performed. 

CHRONIC  LARYNGITIS. 

Synoyiyms. — Chronic  catarrh  of  the  larynx,  laryngitis  chronica. 

The  chronic  inflammation  of  the  larynx  indicated  by  more  or  less 
hoarseness  and  cough  with  a  frequent  inclination  to  clear  the  throat  is 
most  common  in  mole  adults. 

Anatomical  and  Pathological  Characteristics. — There  is  hy- 
peremia of  the  parts,  which  may  be  general  or  circumscribed,  shading 
off  gradually  into  the  color  of  the  surrounding  tissue.  Usually  there  is 
but  little  swelling,  occasionally  small  blood  vessels  upon  the  epiglottis  or 
the  vocal  cords  are  enlarged,  and  in  rare  instances  nodular  excrescences 


CHRONIC  LARYNGITIS.  399 

are  met  with.  Xot  infrequently  slight  erosions  are  noticed,  particularly 
between  tbe  arytenoid  cartilages,  but  often  these  consist  simply  of  de- 
struction of  the  epithelium  and  cannot  be  distinguished  except  by  the 
absence  of  the  peculiar  glistening  appearance  characteristic  of  healthy 
mucous  membrane.  Exceptionally  small  ulcers  occur  upon  the  vocal 
cords  at  the  vocal  processes  (Fig.  101). 

In  unusual  instances  hypertrophy  of  the  soft  tissues  exists. 

Etiology. — The  disease  is  occasionally  primary,  but  more  frequently 
it  is  the  result  of  repeated  attacks  of  acute  or  subacute  inflammation, 
and  therefore  is  generally  due  to  like  causes.  The  excessive  use  of 
tobacco,  chronic  alcoholism,  and  the  constant  inhalation  of  irritating 
dust  or  particles  of  metal  as  observed  in  metal-grinders,  millers,  and 
others,  may  sometimes  be  classed  as  causes.  Kot  infrequently  the  dis- 
ease follows  from  over-use  of  the  voice,  especially  in  the  open  air,  or 
when  the  individual  is  already  suffering  from  acute  or  subacute  inflam- 


Fig.  101.— Catarrhal  Ulcer  of  the  Vocal       Fig.    10?. — Chronic    Catarrhal   Laryngitis 
Cord.  with  Deformity. 

mation  of  the  organ.  The  disease  sometimes  is  a  sequel  of  measles, 
scarlatina  or  other  eruptive  fevers,  and  in  rare  instances  it  results 
from  eczema. 

All  long  continued  affections  of  the  larynx,  as  cancer,  lupus,  or  poly- 
poid growths,  may  finally  set  up  chronic  inflammation.  Phthisis  and 
syphilis  are  frequent  causes. 

Symptomatology. — In  some  cases  the  symptoms  are  not  marked,  and 
the  patient  only  complains  of  something  wrong  in  the  larynx,  with 
hoarseness  and  more  or  less  dryness  of  the  throat,  especially  after  expo- 
sure. These  patients  often  expectorate  small  pellets  of  thickened  mucus. 
Sometimes  they  are  suddenly  startled  in  the  night  or  at  other  times 
with  a  sense  of  suffocation  due  to  spasm  of  the  glottis,  and  attended  by 
a  feeling  as  though  a  crumb  of  bread  had  dropped  upon  the  vocal  cords. 
In  mild  cases  there  are  no  constitutional  symptoms,  but  in  those  more 
severe  there  may  be  emaciation,  fever,  and  night  sweats,  as  results  of 
the  disturbance  caused  by  the  frequent  cough.  Among  the  common 
sensations  experienced,  are  pricking  or  burning  in  the  throat  and  a 
frequent  desire  to  clear  it.  Varying  degrees  of  hoarseness  are  observed; 
in  some  this  symptom  is  noticed  during  ordinary  conversation,  in  others 
only  when  singing,  and  in  still  others  the  singing  voice  seems  natural,  al- 


400  DISEASES  OF  THE  LARYNX. 

though  the  voice  is  very  hoarse  in  its  ordinary  use.  In  others  difficulty  is 
noticed  only  on  attempts  at  shouting.  Sometimes  early  in  the  morning 
the  patient  is  very  hoarse,  but  after  two  or  three  hours  the  voice  becomes 
nearly  normal  as  a  result  of  physiological  stimulation  of  the  circulation 
in  the  parts.  In  these  cases,  the  voice  usually  again  becomes  hoarse 
after  a  few  hours.  In  some  instances  taking  of  food  greatly  clears  the 
voice.  In  some  the  cones  are  clear  during  quiet  conversation,  and 
hoarseness  is  only  experienced  after  talking  or  singing  for  a  half-hour 
or  more.  In  nearly  all  cases,  however,  the  voice  eventually  becomes 
continuously  strained.  Persons  suffering  from  this  disease  commonly 
tire  easily  on  attempting  to  talk  for  any  length  of  time,  and  with  the 
fatigue  the  voice  usually  becomes  more  and  more  harsh  and  unnatural. 

The  fatigue  resulting  from  exertion  of  the  parts  may  be  confined  to 
the  larynx,  or  it  may  be  general,  so  that  even  strong  subjects  suffering 
from  laryngitis  may  become  much  exhausted  after  using  the  voice  for 
half  an  hour.  Eespiration  is  not  affected,  barring  those  instances  where- 
in the  laryngeal  opening  is  considerably  narrowed  by  inflammatory 
changes.  The  cough  usually  consists  of  simple  hemming  efforts  to 
clear  the  larynx  of  small  pellets  of  mucus,  but  it  sometimes  becomes 
frequent  and  severe,  especially  during  the  night. 

Two  kinds  of  laryngeal  cough  may  occur  in  this  disease :  one  dry,  harsh, 
and  brassy,  with  little  or  no  expectoration;  the  other  moist,  the  sputum 
being  brought  up  with  little  difficulty.  This  latter  type  is  usually  asso- 
ciated with  chronic  bronchitis,  in  which  case  the  expectoration  may  be 
abundant.  As  a  rule,  the  sputum  consists  of  small  masses  of  mucus,  gray- 
ish in  color  from  being  more  or  less  tinged  with  dust;  after  a  time  it 
may  become  yellowish  or  brownish.  The  tongue  is  usually  thick  and 
coated  at  its  base  with  a  yellowish  pasty  fur.  The  mucous  membrane  of 
the  fauces  and  pharynx  is  generally  relaxed  and  more  or  less  congested, 
and  in  many  instances  enlarged  follicles  may  be  seen  upon  the  pharyn- 
geal wall  or  base  of  the  tongue.  The  general  health  is  not  usually  im- 
paired, the  appetite  remains  good,  but  constipation  is  common  and  oc- 
casionally there  are  symptoms  of  dyspepsia.  The  mucous  membrane  of 
the  larynx  is  more  or  less  red  and  slightly  swollen  either  uniformly  or 
in  patches;  the  latter  condition  is  more  apt  to  be  noticed  on  the  vocal 
cords  and  the  arytenoids,  but  may  involve  the  ventricular  bands  or 
epiglottis. 

Sometimes  nodular  excrescences  exist,  varying  in  size  from  one  to 
five  millimetres  in  diameter;  these  give  the  larynx  a  granular  appear- 
ance. This  is  especially  noticeable  upon  the  vocal  cords  in  the  con- 
dition known  as  trachoma.  In  some  cases  slight  erosions  may  be 
seen,  being  more  apparent  by  the  loss  of  that  "  peculiar  sheen  "  which  is 
seen  upon  the  healthy  mucous  membrane  than  by  a  visible  depression. 
This  condition  is  most  likely  to  occur  on  the  inner  surfaces  of  the  ary- 
tenoid cartilages  just  above  the  posterior  ends  of  the  vocal  cords.     The 


CHRONIC  LARYNGITIS.  401 

laryngeal  mucous  membrane  is  sometimes  dry,  but,  as  a  rule,  the  secre- 
tions are  somewhat  increased.  Often  flakes  of  more  or  less  discolored 
mucus  may  be  seen  adhering  to  the  cords  or  slightly  sticking  them  to 
each  other,  and  in  other  instances  a  less  tenacious  and  thinner  secretion 
is  seen  in  a  very  thin  layer  upon  the  cords  and  other  portions  of  the 
larynx,  or  stretching  between  the  vocal  cords  in  respiration,  but,  as  be- 


Fig.  103.— Chronic  Catarrhal  Laryngitis.  Fig.  104.— Catarrhal  Laryngitis  with  De- 

formity Simulating  Cancer. 

fore  mentioned,  the  secretion  is  never  abundant  if  only  the  larynx  is 
involved.  In  many  examples  of  the  disease  the  tracheal  mucous  mem- 
brane is  also  congested,  and  often  secretions  may  be  seen  collected  upon 
its  surface.  There  is  as  a  rule  comparatively  little  thickening  of  the 
laryngeal  tissues,  excepting  the  vocal  cords,  which  may  be  swollen  to 
two  or  three  times  their  normal  size — but  the  epiglottis  or  one  or  both 
arytenoids  may  be  thickened  from  twenty  to  fifty  per  cent. 

In  unusual  instances  all  the  soft  parts  are  hypertrophied,  and  exceptionally 
the  changes  are  so  great  as  to  simulate  malignant  disease,  or  aggravated  forms 
of  syphilitic  laryngitis.  It  has  been  stated  that  the  larynx  sometimes  appears 
to  be  dilated,  but  I  have  not  seen  this  condition. 

Subglottic  hypertrophy,  consisting  of  a  grayish  welt  just  below  the 
vocal  cord,  is  occasionally  seen,  and  it  is  probable  that  the  same  condition 


Fig.  105.— Slight  Subglottic  CEdema  in  a  Phthisical  Patient. 

at  the  outer  portion  of  the  under  surface  of  the  cord  may  account  for 
some  of  those  cases  of  hoarseness  where  the  physical  condition  of  the 
larynx  appears  nearly  or  quite  normal.  This  condition  might  easily 
escape  observation  because  of  its  location  beneath  the  cord.  Sluggish 
movement  of  the  cords  or  want  of  proper  approximation  is  not  uncom- 
26 


402  DISEASES  OF  THE  LARYNX 

monly  the  result  of  mechanical  interference  with  contraction  of  the  laryn- 
geal muscles,  or  thickening  and  irregularities  of  the  mucous  membrane. 
The  glands  at  the  base  of  the  tongue  are  quite  often  enlarged,  and  some- 
times they  seem  to  stand  in  a  causative  relation  to  the  laryngitis.  In 
some  instances  a  varicose  condition  of  the  veins  may  be  noticed  in  the 
same  locality.  The  pharyngeal  wall  may  be  normal  or  it  may  be  relaxed 
and  studded  with  enlarged  follicles,  while,  again,  it  will  be  found  dry  and 
glazed,  or  partially  coated  with  secretion.  Perhaps  the  most  constant 
changes  which  accompany  chronic  laryngitis  are  found  in  the  nasal  cav- 
ities, which  in  the  majority  of  cases  are  more  or  less  obstructed  by  exos- 
tosis or  enchondrosis  of  the  septum,  or  by  hypertrophy  or  swelling  of 
the  turbinated  bodies. 

Diagnosis. — The  disease  may  be  mistaken  for  paralysis  of  the  vocal 
cords,  oedema  of  the  larynx,  tubercular  or  syphilitic  laryngitis,  or  for 
cancer;  a  definite  distinction  only  being  possible  after  careful  laryngo- 
scopy examination.  In  chronic  catarrhal  laryngitis  the  parts  nearly 
always  remain  of  normal  contour,  and  are  but  little  swollen,  though 
more  or  less  congested;  ulceration  is  rare. 

Constant  hoarseness  is  caused  by  paralysis  of  the  vocal  cords,  and 
dysphonia  is  especially  pronounced  when  the  patient  is  fatigued ;  there- 
fore the  voice  is  usually  better  in  the  early  morning  than  in  the  evening. 
In  simple  catarrhal  inflammation,  the  hoarseness  is  generally  worse  early 
in  the  morning.  In  paralysis,  there  is  no  congestion  or  swelling,  but 
there  is  marked  loss  of  movement  of  one  or  both  cords,  in  which  respect 
it  differs  from  laryngitis. 

Chronic  laryngitis  is  to  be  distinguished  from  paralysis  of  the  vocal 
cords  by  the  following  characteristics : 

Chronic  catarrhal  laryngitis.  Paralysis  of  the  vocal  cords. 

Parts  slightly  thickened.     More  or  No  swelling  or  congestion, 

less  congestion. 
Slight  loss  of  movement  of  cords.  Marked  loss  of  movement  of  one  or 

both  cords. 
Hoarseness  usually  most  marked  in  Constant  hoarseness;  usually  less  in 

the  morning.  the  morning. 

Dysphonia    especially     pronounced 
when  patient  is  fatigued. 

Swelling  of  the  mucous  membrane  is  caused  by  oedema  of  the  larynx, 
the  parts  generally  appearing  from  three  to  five  times  as  large  as  normal. 
The  mucous  membrane  is  usually  pale  and  has  a  semi-transparent  ap- 
pearance. Sometimes  it  may  be  considerably  congested,  but  in  all  cases 
it  appears  as  though  serum  would  flow  out  if  the  membrane  were  punc- 
tured.    In  these  respects  chronic  laryngitis  is  quite  different. 

From  oedema  of  the  larynx,  chronic  laryngitis  is  to  be  distinguished 
as  follows : 


CHRONIC  LARYNGITIS.  403 

Chronic  catarrhal  laryngitis.  CEdema  of  the  larynx. 

Prolonged  course;  slight  swelling  of  Short  duration  ;   great   swelling  of 

parts,    with   more  or  less  redness  of  parts,  with  change  of  color;  membrane 

membrane.  pale,  semi-transparent. 

Respiration  normal.  Labored  respiration. 

Simple  catarrhal  inflammation  is  distinguished  from  tuberbular 
laryngitis  by  the  history,  by  the  constitutional  symptoms  and  by  the  color 
and  contour  of  the  parts.  In  the  early  stage  of  tubercular  laryngitis 
there  is  frequently  anaemia  of  the  organ  and  sometimes  of  the  soft  palate, 
instead  of  congestion  as  in  chronic  catarrhal  inflammation.  In  some 
cases,  however,  the  color  in  the  two  diseases  is  not  very  dissimilar;  but 
in  the  tubercular  affection  superficial  or  occasionally  deep  ulceration  of 
the  vocal  cords  and  ventricular  bands  or  of  the  posterior  commissure, 
or  the  epiglottis,  are  soon  discoverable,  which  are  not  observed  in  the 
simple  catarrhal  disease.  In  the  later  stage  of  most  cases  of  tubercular 
laryngitis  there  is  peculiar  pyriform  swelling  of  the  arytenoids  and  ary- 
epiglottic  folds,  the  parts  being  paler  than  in  health,  three  or  four  times 
their  ordinary  thickness,  and  having  an  appearance  of  solidity  instead  of 
that  of  oedema.  Ulceration  is  usually  associated  with  this  condition,  or, 
if  not  present  at  first,  it  speedily  follows.  The  loss  of  strength,  rapid 
pulse,  fever,  emaciation,  and  night  sweats  of  tubercular  laryngitis  are 
very  seldom  found  in  the  simple  catarrhal  inflammation.  In  the  tuber- 
cular affection  pain  is  a  common  and  distressing  symptom,  but  it  seldom 
occurs  in  the  disease  under  consideration.  Again,  in  the  tubercular 
affection  there  are  generally  signs  of  disease  in  the  apices  of  the  lungs. 

Simple  catarrhal  inflammation  and  syphilitic  laryngitis  cannot  be  dis- 
tinguished in  all  instances,  especially  when  there  is  simple  redness  with 
slight  swelling,  although  usually  the  history  of  the  case,  the  old  cica- 
trices in  the  pharynx,  with  scars  or  deep  ulcers  in  the  larynx,  and  distor- 
tion and  thickening  of  the  organ,  which  has  a  peculiarly  dense  appear- 
ance as  compared  with  oedema  or  tuberculosis,  are  sufficient  to  enable 
the  physician  to  make  an  accurate  diagnosis. 

Between  chronic  catarrhal  laryngitis  and  syphilitic  laryngitis  the 
following  are  the  chief  points  of  difference: 

Chronic  catarrhal  laryngitis.  Syphilitic  laryngitis. 

No  specific  history.  Syphilitic  history. 

Normal  contour  of  parts.  Sometimes    distortion    of  parts    by 

old  cicatrices  or  thickening. 
No  evidences  of  ulceration,  past  or  Mucous  patches,  scars,  or  ulcers  gen- 

present,  erally  present. 

We  find  malignant  disease  of  the  larynx  usually  attended  by  more  or 
less  pain  and  marked  in  the  beginning  by  circumscribed  congestion 
which   is   speedily   followed  by  the   development  of  a  neoplasm,  that 


4(>4  DISEASES  OF  THE  LARYNJT. 

gradually  advances,  involving,  as  a  rule,  all  of  the  tissues  with  which  it 
conies  in  contact,  causing  distortion  of  the  larynx,  and  finally  undergoing 
deep  ulceration.  Catarrhal  laryngitis  never  has  this  history,  though  I 
have  seen  a  few  cases  in  which  the  swelling  and  distortion  of  the  parts 
were  strongly  suggestive  of  malignant  disease.  In  such  instances  noth- 
ing but  continued  observation  of  the  case  for  some  time  will  enable  the 
physician  to  make  an  accurate  diagnosis. 

The  differential  diagnosis  of  chrouic  catarrhal  laryngitis  and  malig- 
nant disease  of  the  larynx  is  as  follows : 

Chronic  catarrhal  laryngitis.  Malignant  disease  of  larynx. 

Moderate    uniform    congestion   and  Circumscribed  redness  and  swelling; 

thickening  of  parts.  contour  of  parts  much  changed. 

No  pain.  Pronounced  pain. 

Hoarseness,  but  no  dysphagia.  Aphonia  and  dysphagia. 

No  ulceration.  Eventually  ulceration,  with  offensive 

discharge. 

Prognosis. — The  disease  usually  runs  a  very  protracted  course,  last- 
ing for  months  or  years,  though  there  is  a  strong  tendency  to  improve- 
ment at  times,  with  subsequent  recurrence  of  the  more  pronounced 
symptoms.  It  very  rarely,  if  ever,  terminates  fatally;  yet  there  is  some 
reason  for  believing  that  very  protracted  inflammation,  after  involving 
the  trachea  and  bronchial  tubes  in  greatly  debilitated  patients,  may 
eventually  terminate  in  consumption.  The  disease  is  not  intractable  if 
the  exciting  causes  can  be  removed  and  the  predisposing  tendency  cor- 
rected. 

Treatment. — In  every  case  of  chronic  laryngitis  it  is  the  first  duty 
of  the  physician  to  remove  the  causes  if  possible.  With  this  end  in 
view,  the  excessive  use  of  tobacco  and  alcoholic  stimulants,  and  some- 
times even  the  use  of  tea  and  coffee,  should  be  interdicted  and  the  con- 
dition of  the  digestive  organs  must  be  carefully  regulated.  The  patient 
must  avoid  all  exposure  to  damp  and  cold,  or  to  the  vitiated  atmosjmere 
of  crowded  rooms.  He  must  avoid  the  inhalation  of  irritating  dust  and 
gases,  and  must  keep  the  skin  and  other  excretory  organs  in  a  healthy 
condition.  The  parts  involved  should  be  placed,  as  nearly  as  possible,  at 
rest,  especially  during  all  acute  exacerbations  of  the  disease.  Singing, 
shouting,  and  excessive  use  of  the  voice,  especially  in  the  open  air,  must 
be  prohibited;  and  when  there  is  much  irritability  of  the  parts,  the 
patient  should  converse  only  in  whispers.  There  are  some  cases,  how- 
ever, of  a  chronic  low  grade  of  inflammation  that  seem  benefited  by 
moderate  use  of  the  voice,  which  stimulates  a  flow  of  blood  through  the 
parts,  and  thus  promotes  absorption  of  inflammatory  products.  Usually 
prolonged  systematic  treatment,  consisting  of  repeated  ajiplications  of 
stimulating  substances,  will  be  necessary  before  the  disease  can  be  cured. 
The  various  substances  used  for  this  purpose  may  be  applied  in  the  form 


CHRONIC  LARYNGITIS. 


405 


of  ponders,  sprays,  or  pigments  according  to  the  tolerance  of  the  patient 
and  the  inclination  of  the  physician.  As  a  rule,  sprays  give  the  patient 
less  inconvenience  and  are  on  the  whole  preferable,  though  occasionally 
powders  answer  an  excellent  purpose,  and  sometimes  pigments,  espe- 
cially when  applied  by  means  of  a  cotton  probang  (Fig.  107),  are  very 
effectual.  These  applications  should  be  made,  when  possible,  every  day 
for  one  or  two  weeks,  until  considerable  acute  congestion  of  the  parts 
has  been  excited;  then  once  in  two  days  for  a  week  or  two,  and  after  this 
less  frequently,  according  to  the  improvement  of  the  case.     It  is  well 


Fig.  106. 


Fig.  107. 


Fig.  106.— Davidson's  Atomizers,  Set  No.  66,  for  Office  Use  (1-3  size).  For  the  specialist, 
to  whom  time  is  an  object,  it  will  be  found  preferable  to  have  these  bottles  held  by  an  open  spring- 
clip  to  the  edge  of  a  shelf.  The  facility  with  which  the  tips  may  be  changed  to  throw  a  spray  in  any 
direction  makes  each  of  these  bottles  equivalent  to  four  of  the  atomizer  tubes  in  common  use. 
They  may  be  used  with  the  hard  rubber  attachment  shown  at  bottom  of  cut  but  more  conveniently 
with  the  Davidson  cut-off. 

Fig.  107.— Ingals1  Laryngeal  Applicator  (copper  staff,  2-5  size).  The  cotton  should  be  wound 
firmly  upon  the  point,  and  to  prevent  the  possibility  of  accident  a  thread  should  be  tied  about  it 
with  a  slip-knot  and  wound  about  the  staff  up  to  the  handle. 

also  to  have  the  patient  at  the  same  time  use  weaker  applications  to  the 
larynx  by  sprays  or  inhalation  each  morning  and  evening.  It  will  be 
found  that  different  larynges  vary  exceedingly  in  sensitiveness,  so  that 
an  application  which  will  cause  no  discomfort  whatever  in  one  may  in 
another  produce  extreme  pain.  It  is  therefore  necessary  to  try  weak 
medication  at  first,  and  always  to  regulate  the  strength  by  the  effect, 
which  may  be  judged  quite  accurately  by  the  sensations  of  the  patient. 

Applications  which  are  made  by  the  patient  himself  should  never 
cause  discomfort  for  more  than  twenty  or  thirty  minutes.     Those  made 


406  DISEASES  OF  THE  LARYNX. 

by  the  physician,  if  daily,  should  not  cause  smarting  for  more  than  an 
hour,  and,  if  every  second  day,  not  more  than  two  hours;  in  either  case 
actual  pain  should  not  last  more  than  ten  or  fifteen  minutes.  The  par- 
ticular remedy  to  be  employed  is,  as  a  rule,  a  matter  of  little  conse- 
quence, the  object  being  merely  to  stimulate  the  mucous  membrane; 
though  it  will  be  found  that  in  some  cases  one  substance  will  really 
work  better  than  any  other.  In  most  instances  a  change  from  time  to 
time  will  hasten  recovery,  for  where  a  single  agent  is  used  for  a  long 
period  the  parts  appear  to  become  so  accustomed  to  it  that  it  has  but 
little  effect  upon  them.  The  topical  remedies  commonly  employed  in 
this  disease  consist  of  zinc  sulphate  or  chloride  in  solutions  varying 
in  strength,  from  gr.  ij.  to  xxx.  ad  3  i.  of  distilled  water;  solutions 
of  iron  chloride,  nj,  lx.  to  cxx.  ad  3  i.;  iron  and  ammonium  sulphate, 
gr.  v.  to  xxx.  ad  3  i.,  or  copper  sulphate,  gr.  x.  to  xx.  ad  3  i. ;  silver 
nitrate,  gr.  x.  to  5  ij.  ad  3  L;  tannin,  gr.  xxx.  to  3  i.  ad  3  i.  Tincture  of 
iodine  or  turpentine,  the  fluid  extract  of  thuja  occidentalis,  and  vari- 
ous other  substances  are  also  in  common  use.     The  zinc  and  copper 

salts  have  proved  most  satisfactory  in  my 
hands.  Usually  in  the  beginning  I  apply  a 
spray  of  a  solution  of  zinc  sulphate,  gr.  ij. 
ad  3  L,  and  if  this  causes  no  discomfort  a 
small  quantity  of  a  solution  of  gr.  xxx.  ad  3  i. 
is  applied  immediately  afterward,  and  should 
no  smarting  result,  a  more  thorough  appli- 
cation of  it  is  made,  the  aim  being  to  produce 
a  reaction  which  the  patient  will  feel  for  one 

BAYIPJ0H   RUBBER  CC  ..,-.. 

fig.  loa-DAYiiMON's  atomjzek,  °r  two  hours.  At  the  next  visit  the  solution 
No.  59,  old  Style,  screw  Top,  Long  may  be  modified  according  to  the  effect  which 
tip  (Usize).  jms  ^een  obtained,  and  the  time  that  it  has 

been  felt.  Other  remedies  may  be  employed  in  the  same  manner.  I 
usually  make  these  applications  in  the  form  of  spray  with  an  air  pres- 
sure of  thirty  or  forty  pounds  to  the  inch.  The  swab  I  seldom  use,  and 
the  brush  not  at  all.  I  rarely  employ  tincture  of  iodine  or  silver  nitrate, 
though  sometimes  they  are  of  great  benefit.  The  strong  solutions  of 
the  latter  recommended  by  some  authors  are  in  most  cases  objectionable, 
because  of  the  spasm  of  the  larynx  and  the  great  discomfort  they  cause, 
while  their  beneficial  effects  are  seldom  greater  than  those  of  milder  ap- 
plications. For  use  at  home  I  give  the  patient  weak  solutions  of  similar 
astringents  (Form.  88,  92,  94).  These  the  patient  applies  cold  with 
some  suitable  atomizer. 

Steam  sprays  seem  to  cause  relaxation  of  the  parts,  which  favors  sub- 
sequent inflammation,  and  therefore  they  are  not  recommended.  How- 
ever, they  may  sometimes  be  used  with  more  or  less  benefit  at  night 
or  when  the  patient  is  not  going  out  of  doors  for  one  or  two  hours. 
Lennox  Browne  particularly  recommends  such  inhalations  as  benzoin, 


CHRONIC  LARYNGITIS.  407 

phenol,  creasote,  or  camphor.  If  these  are  used  with  warm  water,  the 
patient  must  not  go  out  of  doors  for  some  time  afterward.  They  may 
be  employed  in  some  of  the  lighter  oils,  as  for  example,  liquid 
albolene,  and  applied  by  means  of  some  of  the  various  nebulizers  or 
atomizers  without  the  danger  incident  to  the  use  of  warm  vapors. 

The  substances  most  commonly  used  in  the  larynx  in  the  form  of 
powder  are  bismuth,  boric  acid,  iodoform,  iodol,  berberine  muriate,  gum 
benzoin,  myrrh,  alum,  zinc  sulphate,  and  silver  nitrate.  Boric  acid  and 
iodol  or  iodoform  in  equal  parts  constitute  a  very  useful  stimulant  and 
antiseptic  application  in  some  cases.  Boric  acid  alone  is  slightly  more 
stimulating.  Equal  parts  of  gum  benzoin,  bismuth,  and  iodol  or  iodoform 
make  an  excellent  powder,  still  more  stimulating.  Tannin,  in  the  pro- 
portion of  from  two  to  ten  per  cent,  with  sugar  of  milk,  is  sometimes 
useful.  One  part  of  berberine  muriate  to  two  parts  of  acacia  forms  an 
excellent  application  for  certain  cases,  especially  where  there  is  a  relaxed 
condition  of  the  mucous  membrane  and  enlargement  of  the  follicles. 
Equal  parts  of  alum  and  sugar  of  milk  answer  well  when  a  decided 
effect  is  desired.  Silver  nitrate  I  never  employ  in  this  way,  though  it  is 
recommended  by  good  authority.  With  most  of  these  powders  it  is  well 
to  combine  about  five  per  cent  of  pulverized  starch  to  prevent  packing, 
and  all  of  them  should  be  thoroughly  triturated.  Stimulating  or  seda- 
tive troches  will  often  be  found  beneficial;  of  the  former,  troches  of  am- 
monium compound,  krameria  compound,  or  benzoic  acid  compound  are 
excellent  examples  (Forms.  41,  46,  48).  Of  the  sedative  troches  we 
have  lactucarium,  terpin  hydrate  and  cannabis  compound  (Forms.  29, 
33),  or  morphine,  antimony,  and  ipecac  compound  (Form.  32)  are  good 
examples.  When  cough  is  a  troublesome  feature,  sprays  of  potassium 
bromide  3  ss.  to  3  i.ad  |  i.  will  often  be  found  very  useful. 

Irritating  cough  may  sometimes  be  readily  relieved  by  a  few  light 
inhalations  of  chloroform ;  for  this  purpose  a  small  bottle  may  be  given 
the  patient  to  carry  in  his  pocket  for  use  as  needed.  Aside  from  this 
local  treatment,  it  will  often  be  found  of  the  greatest  importance  to 
cure  coexisting  disease  of  the  pharynx,  base  of  the  tongue,  or  nasal  cav- 
ities. Enlarged  glands  at  the  base  of  the  tongue,  or  varicose  veins, 
should  be  reduced  by  cauterization.  Follicular  enlargements  on  the 
pharyngeal  wall  must  be  cut  down  by  the  cautery,  and  hypertrophic 
rhinitis  or  exostoses  of  the  septum  must  be  met  by  proper  surgical  pro- 
cedures. Other  forms  of  inflammation  or  obstruction  in  the  nares  or 
pharynx  must  also  be  remedied,  for  the  laryngeal  disease  can  seldom  be 
permanently  cured  while  these  affections  remain.  In  some  instances  it 
will  be  found  desirable  to  apply  caustics,  such  as  silver  nitrate,  chromic 
acid,  or  the  galvano-cautery  point  to  enlarged  follicles  in  the  larynx  it- 
self. In  such  cases  the  larynx  should  first  be  thoroughly  anaesthetized 
by  a  twenty  per  cent  or  twenty  five  per  cent  solution  of  cocaine,  and 
then  the  application  should  be  made  accurately  to  the  parts  diseased,  and 


408  DISEASES   OF  THE  LARYNX. 

to  no  other,  care  being  taken  that  the  cauterizations  are  never  extensive 
or  severe.  After  any  of  these  operations  the  patient  should  apply  cold 
compresses  to  the  neck  for  from  twelve  to  twenty-four  hours,  to  prevent 
undue  reaction. 

TRACHOMA  OF  THE  VOCAL  CORDS. 

Synonym. — Chorditis  tuberosa. 

Trachoma  of  the  vocal  cords  is  a  chronic  inflammation  of  the  larynx, 
characterized  by  roughness  or  a  granular  appearance  of  the  vocal  bands, 
■with  some  swelling,  and  more  or  less  alteration  of  the  voice.  It  is 
found  most  frequently  in  singers,  but  may  occur  in  others.  I  have  seen 
one  case  in  the  person  of  a  farmer  who  used  his  voice  very  little  in 
singing. 

Anatomical  and  Pathological  Characteristics. — The  disease 
appears  to  consist  of  hypertrophy  of  the  connective  tissue,  which  results 
in  a  nodular  or  granular  thickening  of  the  cord. 


Fin.  109.—  Trachoma  op  Vocal  Cords  (extreme). 


Etiology. — No  special  causes  of  the  affection  are  known,  aside  from 
repeated  over-use  of  the  voice  especially  when  the  larynx  is  congested. 

Symptomatology. — The  symptoms  are  those  of  chronic  laryngitis, 
i.e.,  hoarseness  or  aphonia,  with  more  or  less  cough  and  expectoration. 
Upon  laryngoscopic  examination,  the  cords  are  found  congested  and 
thickened,  and  presenting  a  nodular  appearance  (Fig.  109)  of  the  sur- 
face, with  nnevenness  of  the  edges. 

Diagnosis. — The  diagnosis  will  be  based  upon  a  history  of  chronic 
laryngitis,  with  the  physical  appearances  just  mentioned. 

Prognosis. — The  duration  may  be  months  or  years,  but  prolonged 
rest  and  judicious  treatment  will  usually  promote  a  cure. 

Treatment. — The  treatment  consists  of  the  application  of  mild 
caustics  or  mineral  astringents  in  the  same  manner  as  recommended  for 
chronic  laryngitis.  By  this  course,  persistently  carried  out,  a  cure  may 
usually  be  effected.  Owing  to  the  obstinacy  of  this  affection,  Carlo 
Labus,  of  Milan,  has  recommended  flaying  of  the  vocal  cords,  or,  in  other 
words,  stripping  off  of  their  hypertrophied  mucous  membrane  by  means 
of  ordinary  laryngeal  forceps  {Archives  of  Laryngology,  1880).     Charles 


PHLEBECTASI8  LARYNGEA.  409 

E.  Sajous,  of  Philadelphia,  has  recommended  touching  small  areas  of  the 
cord  with  chromic  acid  at  intervals  of  several  days  (Transactions  of 
the  American  Laryngological  Association  for  1888).  This  treatment 
seems  to  promise  well  and  should  be  given  a  fair  trial  after  the  ordinary 
measures  have  proven  unsuccessful.  In  applying  the  chromic  acid,  a 
very  small  portion  should  be  fused  on  the  end  of  a  guarded  applicator 


Fig.  110.— Ingals'  Chromic  Acid  Applicator  and  Handle  (1-3  size).  This  is  a  long  aluminium 
wire,  properly  curved  to  correspond  with  the  f  aucial  angle,  and  guarded  at  the  end  by  a  piece  of 
rubber  tubing  which  protects  the  parts  not  to  be  touched  from  contact  with  the  agent.  The  bit 
of  rubber  tubing  is  prevented  from  slipping  off  by  a  silk  thread  which  is  tied  about  it  and  wound 
around  the  stem  up  to  the  handle. 

(Fig.  110)  with  which  the  part  should  be  accurately  touched,  the  larynx 
having  first  been  anaesthetized  by  cocaine  to  prevent  injury  to  other 
parts. 

PHLEBECTASIS   LARYNGEA. 

Phlebectasis  laryngea  is  a  varicose  condition  of  the  laryngeal  veins, 
characterized  by  more  or  less  alteration  of  the  voice  and  discomfort  in 
the  larynx. 

Anatomical  and  Pathological  Chaeacteristics. — In  mild  cases 
fine  veins  are  seen  running  along  the  epiglottis  and  the  lower  portions  of 
the  ventricular  bands ;  in  more  severe  cases  the  enlarged  veins  appear 
tortuous  and  extend  also  over  the  vocal  cords  and  arytenoid  cartilages. 


<§^>  t^^— ■  S^ 


Fig.  111.— Ingals'  Galvano-Cautery  Handle  (]4,  size).    In  this  the  circuit  is  closed  by  moving 
the  finger  from  the  contact  button. 

Etiology. — There  is  no  known  cause  of  the  disease. 

Symptomatology.— The  patients  usually  complain  of  uneasy  sensa- 
tions in  the  larynx,  of  slight  cough,  and  of  more  or  less  hoarseness. 

Diagnosis. — The  diagnosis  is  made  by  careful  inspection  of  the 
larynx,  care  being  taken  not  to  mistake  for  enlarged  veins  the  blackened 
mucus  which  sometimes  collects  upon  the  surface. 

Treatment. — Topical  applications  of  strong  astringents  may  be 
made,  but  the  most  satisfactory  treatment  consists  of  destruction    of 


410  DISEASES  OF  THE  LARYNX. 

the  vein  by  repeated  small  cauterizations  with  the  galvano-cautery,  a 
period  of  from  ten  days  to  two  weeks  intervening  between  the  opera- 
tions. Intra-laryngeal  cauterization  should  be  made  with  an  electrode 
provided  with  a  small  fine  platinum  tip,  which  will  heat  or  cool  quickly. 
The  best  handle  for  this  purpose  is  one  in  which  the  circuit  is  closed 
on  relieving  the  pressure  from  a  spring  (Fig.  Ill)  instead  of  by  the 
usual  method  of  pressure;  this  allows  the  circuit  to  be  completed  with 
the  least  movement  of  the  electrode. 


CHAPTER    XXIY. 

DISEASES   OF   THE   LARYNX.— Continued. 

MEMBRANOUS  CROUP. 

Synonyms. — True  croup,  exudative  laryngitis,  membranous  laryn- 
gitis. 

Croup,  in  the  strict  sense,  is  a  disease  of  the  laryngeal  mucous  mem- 
brane characterized  by  the  exudation  of  inflammatory  lymph,  forming 
false  membrane,  and  attended  by  more  or  less  muscular  spasm  of  the 
larynx.  Mackenzie  and  some  other  authors,  together  with  a  large  num- 
ber of  the  profession,  believe  it  identical  in  nature  with  diphtheria,  but 
I  am  convinced  that  these  are  two  distinct  diseases.  Most  of  the  older 
writers,  and  not  a  few  of  the  more  recent,  agree  with  Aitken,  who  says 
of  this  affection:  "  Any  one  who  has  seen  much  of  croup  in  children  can 
have  no  difficulty  in  recognizing  it  as  a  disease  distinct  from  diphtheria 
in  its  attack,  its  course,  and  results."  I  know  of  no  better  definition 
for  the  disease  than  that  given  by  Lennox  Browne  (Diseases  of  the 
Throat,  second  edition),  who  defines  it  as  a  pseudo-membranous  inflam- 
mation of  the  air  passages,  non-infectious  and  non-contagious.  The  dis- 
ease occurs  most  frequently  in  children  between  two  and  seven  years  of 
age.  It  seldom  occurs  in  older  children,  and  is  extremely  rare  in  young 
infants  and  in  adults. 

Anatomical  and  Pathological  Characteristics. — The  inflam- 
mation is  almost  entirely  confined  to  that  portion  of  the  larynx  above 
the  cords.  The  false  membrane,  though  deposited  partially  upon  the 
epiglottis  and  ventricular  bands,  is  mainly  found  about  the  glottis  itself 
and  upon  the  vocal  cords.  The  inflammation  may  extend  to  the  sub- 
mucous tissues,  resulting  either  in  spasm  or  paralysis  of  the  laryngeal 
muscles.  The  false  membrane  is  comparatively  thin,  only  involving  the 
epithelial  layer  of  the  mucous  membrane,  whereas  in  diphtheria  the 
whole  thickness  of  the  mucous  membrane  is  affected. 

Etiology. — Those  who  believe  in  the  identity  of  diphtheria  and 
croup  attribute  this  to  a  specific  contagium,  the  action  of  which,  how- 
ever, they  admit  may  be  favored  by  the  usually  recognized  causes  of  the 
diseases.  In  some  instances  there  is  undoubtedly  a  strong  hereditary 
predisposition  to  the  disease,  and  in  a  large  number  of  cases  its  onset  is 
certainly  favored  by  acute  laryngitis.  The  disease  is  also  favored  by 
poor  general  health.     There  is  little  doubt  that  the  majority  of  cases  are 


412  DISEASES  OF  THE  LARYNX. 

directly  due  to  improper  clothing  or  to  life  in  damp,  chilly,  and  ill- 
ventilated  rooms.  The  disease  is  peculiarly  prevalent  in  the  spring  and 
fall  months,  when  the  outdoor  temperature  is  so  warm  that  it  is  hardly 
necessary  for  apartments  to  be  heated,  therefore  at  this  time  many 
houses  are  kept  at  a  temperature  of  from  60°  to  65°  F.  The  adults,  who 
are  working  about,  and  who  are  necessarily  in  higher  strata  of  air  than 
the  children  playing  upon  the  floor,  do  not  notice  the  necessity  for  more 
warmth,  but  the  little  ones  become  chilled,  a  slight  catarrhal  laryngitis 
supervenes,  and,  whether  or  not  this  is  the  direct  cause  of  croup,  it  cer- 
tainly favors  the  development  of  the  false  membrane.  The  disease  is 
not  contagious,  and  it  seems  to  have  been  satisfactorily  demonstrated 
that  it  cannot  be  inoculated  from  the  false  membrane,  though  Mac- 
kenzie and  others  hold  contrary  views.  The  theory  that  this  disorder 
is  often  the  direct  result  of  certain  ptomaines  generated  Avithin  the 
patient's  own  body  seems  to  me  reasonable. 

Symptomatology. — For  the  sake  of  convenience  in  description,  the 
disease  may  be  divided  clinically  into  three  stages — a  catarrhal,  an  exu- 
dative, and  a  suffocative. 

The  catarrhal  stage  is  usually  preceded  for  about  forty-eight  hours 
by  a  feeling  of  malaise  attended  by  slight  fever  and  anorexia;  later 
there  is  considerable  fever,  cough,  hoarseness,  and  some  dyspnoea.  In 
the  latter  part  of  this  stage  the  false  membrane  begins  to  form. 

In  the  exudative  stage  the  false  membrane  is  being  gradually  or 
rapidly  deposited  in  the  larynx,  spasmodic  action  of  the  muscles  be- 
comes more  frequent,  and  dyspnoea  more  and  more  severe.  There  is 
either  hoarseness  or  complete  aphonia,  and  cough  may  or  may  not  be 
troublesome.  Finally,  the  membrane  becomes  so  thick  as  to  seriously 
obstruct  the  glottis,  giving  rise  to  the  last  stage. 

In  the  suffocative  stage,  dyspnoea  is  constant,  but  still  more  or  less 
aggravated  at  times  by  spasm  of  the  laryngeal  muscles.  As  the  stage 
advances,  all  of  the  symptoms  of  gradual  suffocation  supervene,  and 
finally,  in  the  majority  of  cases,  the  patient  dies  from  the  effect  of  im- 
perfect aeration  of  the  blood. 

In  the  first  stage  the  temperature  is  raised  from  one  to  three  degrees, 
and  the  pulse  is  quickened  from  twenty  to  thirty  beats  per  minute;  yet 
frequently  the  friends  may  not  notice  these  symptoms  until  the  child 
is  suddenly  wakened  at  night  struggling  for  breath.  This  jiaroxysm, 
which  is  due  to  spasm  of  the  laryngeal  muscles,  continues  for  a  few  min- 
utes, and  then  may  pass  off  till  the  following  night,  or  other  attacks  may 
occur  from  time  to  time  during  the  same  night.  In  the  interval  be- 
tween the  attacks  the  child  breathes  with  comparative  ease  and  soon 
falls  into  a  troubled  sleep.  It  usually  plays  about  the  house  on  the  fol- 
lowing day,  but  more  or  less  hoarseness  is  noticed,  and  at  night  all  of 
the  symptoms  become  more  aggravated.  Again,  there  may  be  an  inter- 
mission in  the  symptoms  during  the  day  following,  and  it  is  not  un- 


MEMBRANOUS  CROUP.  413 

usual  to  find  the  child  running  about  the  house  after  a  second  night  of 
suffering  and  unrest  from  the  paroxysms  of  true  croup;  but  on  the 
succeeding  night  the  suffocative  stage  generally  begins,  in  which  there 
is  constant  dyspnoea,  with  occasional  paroxysms  which  add  greatly  to 
the  distress.  The  spasms  are  less  pronounced  than  in  the  catarrhal 
stage,  because  carbonic  acid  poisoning  renders  the  muscular  action  slug- 
gish. There  are  some  unfortunate  cases,  however,  in  which  the  disease 
runs  rapidly  through  the  three  stages  and  many  terminate  fatally  within  a 
few  hours.  In  the  exudative  stage,  hoarseness  is  persistent,  there  is  a  pe- 
culiar shrill,  harsh  cough,  which  needs  to  be  heard  but  once  to  be  remem- 
bered, and  occasionally  particles  of  false  membrane  are  cast  off.  Fever 
and  anorexia  are  usually  present,  there  is  constant  dyspnoea,  and  inspira- 
tion and  expiration  are  both  prolonged,  especially  the  former.  The  suffo- 
cative paroxysms  now  become  more  frequent  and  severe.  At  the  onset 
of  one  of  these,  the  child  suddenly  springs  up  in  great  alarm,  the  eyes 
stand  out  like  those  of  one  in  strangulation,  the  nostrils  are  dilated,  and 
the  respiratory  muscles  tense  with  the  violent  effort  at  inspiration ;  in 
a  few  seconds  the  countenance  becomes  livid  and  the  child  almost  ceases 
its  efforts  to  breathe;  but  finally  the  spasm  relaxes,  air  again  enters  the 
lungs,  lividity  disappears,  and  respiration  becomes  once  more  normal,  so 
that  excepting  for  the  hoarseness  it  would  hardly  be  known  that  the 
child  was  ill.  One  such  attack  usually  lasts  two  or  three  minutes,  and 
may  be  renewed  after  a  short  interval  of  rest.  Eecurrence  in  this  man- 
ner may  take  place  several  times;  but  usually  after  the  first  three  or 
four  paroxysms  the  child  falls  into  a  restless  sleep  that  may  last  for  sev- 
eral hours.  If  the  larynx  can  be  examined,  we  find  it  congested,  with 
here  and  there  patches  of  thin,  yellowish  white  membrane  upon  the 
surface.  In  this  stage  the  child  is  extremely  restless,  throwing  itself 
about  the  bed,  or  every  few  moments  asking  to  be  taken  up  or  laid 
down  in  its  fruitless  search  for  comfort  and  the  oxygen  it  needs.  The 
face  and  general  surface  are  ashy  pale,  with  lividity  of  the  lips  and 
finger  nails;  the  skin,  which  has  been  hot  in  the  first  and  second 
stages,  remains  so  in  the  earlier  part  of  this  the  third  stage,  but  later 
becomes  cold  and  is  bathed  in  a  clammy  perspiration.  The  pulse  is 
quick  and  small,  the  voice  weak  or  lost,  and  the  cough  feeble  or  sup- 
pressed. The  tongue  usually  is  coated,  and  there  is  much  thirst,  but 
no  desire  for  food. 

In  the  first  stage  of  the  disease  the  respiration  may  be  accelerated,  as 
in  other  catarrhal  affections  of  the  mucous  membrane,  but  in  the  later 
stages  the  breathing  becomes  slow  and  labored,  and  with  each  inspira- 
tion there  is  sinking  in  of  the  soft  parts  of  the  chest.  This  is  most 
marked  at  the  lower  end  of  the  sternum  and  over  the  false  ribs,  but  it 
is  also  noted  in  the  interclavicular  notch  and  just  above  the  clavicles. 

Diagnosis. — True  croup  may  be  mistaken  for  catarrhal  laryn- 
gitis, laryngismus  stridulus,   or  for  diphtheria.     The  essential  points 


414 


DISEASES   OF  THE  LARYNX. 


in  the  diagnosis  are:  gradually  increasing  hoarseness,  slight  consti- 
tutional symptoms,  dyspnoea  and  the  formation  of  false  membrane 
which  is  confined  to  the  larynx. 

In  catarrhal  laryngitis  there  is  commonly  considerable  pain  in 
coughing,  speaking,  or  swallowing;  there  is  but  little  dyspnoea,  the 
cough  is  short  and  sharp,  there  is  no  expectoration  of  false  membrane, 
and  the  respiration  seldom  becomes  slow  and  labored;  all  of  which 
symptoms  distinguish  it  from  croup.  In  typical  cases  there  is  no  diffi- 
culty in  making  the  diagnosis,  but  it  is  difficult  or  quite  impossible,  in 
complicated  or  obscure  instances,  and  therefore  doubtful  cases  should 
be  treated  as  croup. 

From  acute  laryngitis  the  disease  is  to  be  distinguished  by  the  char- 
acteristics presented  below: 


Membranous  croup. 

Generally  occurs  in  children. 
Slight  congestion  and  swelling. 

Slight  pain  in  coughing,  speaking,  or 
swallowing. 

Cough  harsh  and  stridulous. 

Marked  dyspnoea. 

Slow,  labored  respiration. 

False  membrane  in  larynx. 


Acute  laryngitis. 

Generally  occurs  in  adults. 

Marked  congestion  of  parts,  and 
swelling. 

Marked  pain  in  coughing,  speaking, 
and  swallowing. 

Cough  sharp  and  short. 

Slight  dyspnoea. 

Respiration  nearly  normal,  or  may 
be  increased  in  frequency. 

Tenacious,  scanty  sputum,  but  no 
false  membrane. 


Laryngismus  stridulus  differs  from  croup  in  that  it  comes  on  sud- 
denly when  the  child  is  apparently  well.  It  is  not  attended  by  inflam- 
mation, or  quickening  of  the  pulse,  or  fever,  and  the  dyspnoea  passes 
off  in  a  few  minutes,  leaving  the  child  breathing  with  perfect  ease  until 
another  paroxysm  occurs.  Sometimes  the  paroxysms  are  not  repeated. 
As  soon  as  the  attack  is  over,  the  voice  becomes  normal. 

From  laryngismus  stridulus  croup  is  to  be  distinguished  as  follows: 


Membranous  croup. 

Slight  congestion  and  swelling. 
Fever,  rapid  pulse. 

Slow  in  development. 

Labored  and  slow  respiration,  but 
with  paroxysms  of  more  pronounced 
dyspnoea. 

Aphonia  and  dysphonia  constant. 

Presence  of  false  membrane. 
Comparatively  long  duration,    usu- 
ally two  or  three  days. 


Laryngismus  stridulus. 

No  congestion  or  swelling. 

No  fever,  pulse  normal  except  dur- 
ing paroxysm. 

Sudden  in  its  onset. 

Attack  may  not  be  repeated ;  res- 
piration and  voice  normal  except  dur- 
ing paroxysm. 

Voice  normal  except  during  brief 
paroxysms  of  dyspnoea. 

No  false  membrane. 

Short  duration. 


MEMBRANOUS  CROUP.  415 

Croup  cannot  always  be  distinguished  from  diphtheria,  as  there  are 
some  cases  which  at  first  appear  to  be  simply  true  croup,  but  in  which 
diphtheritic  membrane  is  subsequently  deposited  in  the  pharynx  and 
eventually  paralysis  occurs;  or  other  members  of  the  family  are  at- 
tacked by  diphtheria.  But  in  typical  cases  the  distinguishing  symp- 
toms are  well  marked.  Diphtheria  conies  on  more  suddenly,  and  the 
constitutional  symptoms  are  more  pronounced.  There  is  usually  abun- 
dant false  membrane  in  the  fauces,  and  paralysis  is  a  frequent  sequel. 
The  fever  in  diphtheria  is  more  variable  than  in  croup.  The  dyspnoea 
in  diphtheria  is  slowly  developed,  and  there  is  little,  if  any,  spasm 
of  the  glottis.  Diphtheria  is  often  very  contagious,  croup  is  not  at 
all  so.  An  attack  of  croup  is  usually  preceded  by  two  or  three  days  of 
malaise  or  catarrhal  symptoms,  and  is  finally  suddenly  ushered  in 
during  the  night  by  a  severe  paroxysm  of  dyspnoea;  it  is  attended  by 
mild  but  continuous  and  gradually  progressing  fever;  the  constitu- 
tional symptoms  are  slight,  there  is  no  false  membrane  in  the  fauces, 
and  no  paralysis  following  the  disease. 

True  croup  and  diphtheria  present  the  following  differential  points: 

Membranous  croup.  Diphtheria. 

Malaise   or  catarrhal  symptoms  at  Constitutional  symptoms  developed 

first,  but  constitutional  symptoms  com-  quickly  and  very  pronounced, 
paratiyely  slight. 

Fever  mild,  but  continuous  and  grad-  High  fever  at  first,  later  variable, 
ually  increasing. 

Severe  paroxysm  of  dyspnoea  ushered  Dyspnoea  developed  slowly,  no  de- 

in  suddenly  at  night.  cided  spasm  of  glottis. 

No  false  membrane  in  fauces.  False  membrane  in  fauces. 

Not  contagious.  Often  contagious. 

No  subsequent  paralysis.  Frequently  paralysis  follows. 

Prognosis. — In  unusual  cases  patients  may  die  with  membranous 
croup  within  three  or  four  hours  after  the  first  indications  of  the  dis- 
ease, but  commonly  the  affection  extends  over  two  or  three  days,  and 
sometimes  it  continues  for  a  week.  It  is  probable  that  not  more  than 
twenty  per  cent  of  the  cases  would  recover  without  surgical  interfer- 
ence; and  even  under  the  most  improved  methods,  according  to  Hilton 
Fagge,  sixty  or  seventy  per  cent  die.  It  appears,  however,  that  of  those 
upon  whom  intubation  is  done  by  O'Dwyer's  method  forty  to  fifty  per  cent 
recover.  In  cases  which  progress  favorably  the  false  membrane  gradu- 
ally disappears,  the  spasms  subside,  breathing  becomes  less  and  less  diffi- 
cult, the  sputum  becomes  more  abundant,  the  cough  easy,  and  in  two 
or  three  days  the  child  is  out  of  danger.  In  fatal  cases  the  dyspnoea 
steadily  increases,  the  child  becomes  extremely  restless,  the  cough,  which 
has  been  severe,  loses  its  loud,  croupy  sound,  and  may  become  almost 
inaudible;    the  pulse  grows  feeble  and  rapid,  the  extremities  cold,  the 


416  DISEASES   OFTHE  LARYNX. 

skin  is  bathed  in  cold  perspiration,  and  the  patient  finally  dies  of  exhaus- 
tion, or  gradually  passes  into  a  comatose  condition,  in  which  death  en- 
sues from  carbonic  acid  poisoning.  Occasionally  life  is  cut  short  by  a 
heart  clot  or  by  convulsions,  and  in  some  instances  pulmonary  complica- 
tions are  the  immediate  cause  of  death.  A  few  cases  die  from  suffoca- 
tion caused  by  spasm  of  the  glottis. 

Treatment. — In  the  early  stage  of  the  disease  great  benefit  may  be 
derived  from  the  external  application  of  either  cold  or  heat;  but  which- 
ever is  used  must  be  employed  continuously,  as  the  alternate  use  of 
cold  and  he.it  makes  matters  worse.  Cold  may  be  applied  by  cloths 
wrung  out  of  ice  water  and  frequently  changed,  but,  better  still,  by 
means  of  an  ice  bag.  For  this  purpose  a  long,  narrow  rubber  bag  not 
more  than  three  inches  in  width  should  be  obtained  and  filled  about 
half  full  of  ice  cracked  into  small  pieces  not  larger  than  a  filbert.  It 
should  then  be  wrapped  in  a  handkerchief  and  tied  closely  about  the 
neck.  The  ice  will  melt  in  about  an  hour,  and  should  then  be  renewed. 
An  excellent  method  of  applying  cold  is  by  means  of  the  Leiter  coil. 
This  consists  of  a  coil  of  metallic  tubing,  which  may  be  fitted  accurately 
to  the  neck;  to  each  end  is  attached  a  rubber  hose,  one  leading  from  a 
receptacle  of  ice  water,  and  the  other  carrying  off  the  waste.  Continu- 
ous cold  for  the  first  twenty-four  or  forty-eight  hours  will  frequently 
cut  short  the  attack.  Sometimes  because  of  the  depression  of  the 
patient,  and  in  other  instances  to  meet  the  wishes  of  the  friends,  it  is 
better  to  use  heat.  This  may  be  applied  by  means  of  cloths  wrung 
out  of  hot  water,  by  hot  water  bags,  or  by  the  Leiter  coil,  already  re- 
ferred to.  In  the  early  stage  of  the  disease,  heat  may  be  made  to  answer 
exactly  the  same  purpose  as  cold,  but  it  is  usually  more  beneficial  in  the 
later  stages  of  the  attack. 

The  atmosphere  of  the  room  should  be  kept  moist  and  at  a  tempera- 
ture of  75°  or  80c  F.  Moisture  may  be  obtained  by  means  of  a  basin  of 
water  on  the  register  or  stove,  by  the  steam  atomizer,  or  by  constant  slak- 
ing of  lime  in  the  room.  Owing  to  the  fact  that  diphtheritic  membrane, 
when  immersed  in  lime  water  gradually  dissolves,  the  vapors  from 
lime  have  been  considered  especially  beneficial  in  this  disease;  but  it  is 
doubtful  whether  they  are  ever  inhaled  in  sufficient  quantity  or  of  suffi- 
cient saturation  materially  to  affect  the  false  membrane.  Many  physi- 
cians recommend  that  a  basin  of  slaking  lime  be  kept  constantly  in  the 
room  or  upon  the  stove,  others  apply  lime  water  by  means  of  a  steam 
atomizer,  but  probably  the  most  efficient  way  of  using  it  is  by  means  of 
the  croup  tent,  as  follows:  having  placed  a  pan  of  hot  water  close  by 
the  head  of  the  bed  and  dropped  into  it  a  handful  of  unslaked  lime, 
a  sheet  is  thrown  over  the  pan  and  over  the  child's  head,  being  held  up 
somewhat  from  the  face:  the  patient  is  by  this  means  compelled  to 
breathe  the  vapors  arising  from  the  lime.  The  application  should  be 
continued    ten  or  fifteen  minutes  and   repeated   every  half-hour   when 


MEMBRANOUS  CROUP.  417 

practicable.  A  steam  atomizer  may  be  kept  constantly  running  in  the 
room  for  the  purpose  of  saturating  the  air  with  moisture,  and  the 
patient  should  be  induced  to  inhale  from  it  directly  two  or  three  times 
an  hour,  for  five  or  ten  minutes.  For  inhalation  by  means  of  this  instru- 
ment, solutions  of  sodium  bicarbonate  gr.  v.  to  x.  ad  3  i.,  the  saturated 
solution  of  lime  water,  lactic  acid  gr.  xx.  ad  5  i.  to  dissolve  the  membrane, 
or  potassium  bromide  gr.  xx.  to  xxx.  ad  3  i.,  or  the  aqueous  extract  of 
opium  or  belladonna  gr.  i.  to  ij.  ad  3  i.  may  be  employed  to  prevent  the 
paroxysmal  dyspnoea.  Emetics  are  employed  for  the  purpose  of  me- 
chanically dislodging  mucus  and  false  membrane  from  the  larynx,  and 
relaxing  the  muscular  system  so  as  to  prevent  spasms  of  the  glottis. 
For  this  purpose  tartarized  antimony  in  the  form  of  the  compound 
syrup  of  squills  is  probably  the  agent  most  frequently  employed.  It 
should  be  given  in  doses  of  ttj,  xv.  to  xxx.  repeated  every  fifteen  minutes 
until  vomiting  occurs,  or  until  its  depressing  effects  are  noticed;  but  the 
dose  should  not  subsequently  be  repeated  for  several  hours.  Ipecac  in 
some  form  is  used  for  the  same  purpose,  and  it  has  the  advantage  over 
tartarized  antimony  of  causing  no  subsequent  depression.  Zinc  sul- 
phate, alum,  and  turpeth  mineral  are  also  employed ;  the  latter  has  been 
especially  recommended  by  so  eminent  an  authority  as  Fordyce  Barker, 
who  considered  it  prompt,  safe,  and  efficient  in  closes  of  grs.  i.  to  iij. 
Emesis  usually  follows  its  administration,  in  from  five  to  twenty  minutes. 
Pulverized  alum,  gr.  xx.  ad  3  i.,  mixed  with  honey  is  a  prompt,  safe,  and 
not  unpleasant  emetic  in  these  cases.  Mercurial  preparations  have  been 
recommended  for  the  purpose  of  limiting  the  formation  of  false  mem- 
brane, and  within  the  last  few  years  mercury  bichloride  has  been  much 
employed  in  comparatively  large  and  frequent  doses.  I  prefer  the  mild 
chloride,  which  is  more  easily  managed  and  quite  as  efficient.  Turpeth 
mineral  is  also  used  by  some  physicians  in  small  and  repeated  doses  for 
the  same  purpose.  In  children  one  or  two  years  of  age,  I  frequently 
order  one  grain  of  calomel  to  be  given  every  hour  until  it  acts  upon  the 
bowels,  and  subsequently  every  two  hours  for  ten  or  fifteen  doses.  A 
healthy  child  of  this  age  will  usually  be  speedily  purged  by  one  grain  of 
calomel,  but  in  croup  about  twenty  grains  will  generally  be  taken 
before  the  effects  of  the  remedy  are  noticed  upon  the  bowels,  and  then 
it  does  not  act  vigorously.  Thus,  these  patients  often  take  from  thirty 
to  forty  grains  of  calomel  within  thirty-six  or  forty-eight  hours,  and 
I  have  never  seen  any  deleterious  effects  from  its  use,  but  have  fre- 
quently witnessed  the  most  gratifying  results  in  the  relief  of  the  laryn- 
geal symptoms.  Unfortunately,  however,  in  the  majority  of  cases,  no 
matter  what  external  applications  we  employ,  or  what  internal  remedies 
are  administered,  the  disease  goes  steadily  on  from  bad  to  worse;  the 
glottis  becomes  narrower  until  finally  suffocation  is  imminent,  and  then 
we  must  resort  to  surgical  measures  or  the  child  is  lost. 

Mackenzie  recommended  a  croup  brush  in  which  the  hairs  run  toward 
27 


418 


DISEASES  OF  THE  LARYNX. 


the  handle,  designed  to  be  introduced  through  the  glottis  and  withdrawn 
so  as  to  dislodge  the  false  membrane.  I  do  not  know  how  efficient  this 
has  proved,  but  it  has  not  become  popular  with  the  profession.  In  a 
few  instances  an  ordinary  catheter  has  been  passed  through  the  glottis, 
by  which  the  patient  has  been  enabled  to  obtain  sufficient  air  to  support 
life.  In  this  extremity  we  should  not  temporize,  but  should  resort  at  once 
to  O'Dwyer's  intubation,  or  to  tracheotomy,  either  of  which,  if  performed 
early,  will  save  many  lives.  In  children  under  five  years  of  age  intuba- 
tion seems  to  offer  better  chances  for  recovery  than  tracheotomy;  there- 
fore it  should  be  advised,  and  because  of  the  ease  of  its  performance,  the 
readiness  with  which  the  consent  of  parents  is  obtained,  the  speedy  re- 
lief afforded,  and  the  avoidance  of  an  anaesthetic,  it  may  be  recommended 
in  all  cases,  for  it  is  no  bar  to  the  subsequent  performance  of  trache- 
otomy if  that  operation  should  seem  necessary.  The  best  cases  for 
either  of  these  operations  are  those  in  which  the  membrane  is  confined 
to  a  small  portion  of  the  larynx  and  where  the  carbonic  acid  poisoning 


O  CDOQ<o>o 


Fig.  112.— O'Dwyer's  Ixti/batiox  Instruments  i>4  size).    //,  Applicator;  A,  obturator; 
B,  H.  tubes  of  various  sizes;  C.  C,  actual  calibre  of  tubes. 

is  not  very  pronounced;  when  the  difficulty  of  respiration  has  continued 
for  several  hours,  giving  rise  to  pulmonary  atalectasis,  or  oedema,  or  to 
heart  failure,  little  can  be  hoped  from  either.  When  the  glottis  becomes 
so  obstructed  that  there  is  falling  in  of  the  soft  parts  of  the  chest  with 
each  inspiration,  and  respiration  is  long  and  labored,  the  lips  blue  and 
the  skin  pale,  there  should  be  no  delay  in  adopting  surgical  measures, 
for  every  hour  then  will  materially  lessen  the  chances  of  recovery. 

Intubation  is  performed  by  means  of  the  instrument  (Fig.  112) 
devised  by  Joseph  O'Dwyer,  of  New  York.  His  set  of  instruments  con- 
sists of  six  tubes  graduated  for  children  less  than  ten  years  of  age.  It 
contains  a  gauge  for  measuring  the  tubes  to  determine  the  proper  size 
for  any  given  age,  an  applicator  for  introducing  the  tube,  an  extractor 
for  withdrawing  it,  and  a  mouth  gag ;  the  latter,  however,  is  not  as  satis- 
factory as  some  others,  because  the  child  is  sometimes  able  to  displace  it 
from  between  the  jaws  and  may  bite  the  operator.  But  the  other  in- 
struments, which  were  the  outcome  of  long  and  patient  experimenta- 
tion, are  so  nearly  perfect  that  it  has  been  difficult  in  any  way  to  im- 


MEMBRANOUS  CROUP.  419 

prove  upon  them.  Henrotin's,  Waxham's,  or  Allingham's  gags  (Figs. 
113,  114, 115)  are  preferable.  In  preparing  for  the  operation,  the  child's 
age  having  been  ascertained,  the  proper  tube  is  selected  and  a  strong 
thread  about  three  feet  in  length  is  passed  through  the  eyelet  in  its  head 
and  the  ends  are  tied  together;  the  applicator  is  then  screwed  into  the 
obturator,  and  this  passed  through  the  tube  ready  for  the  operation. 
The  head  of  the  tube  is  bevelled  so  that  one  side  is  much  shorter  than 
the  other,  and  this  short  side  should  be  placed  toward  the  handle  of  the 


Fig.  113. — Henrotin's  Gag  (}<$  size).  Fig.  114. — Waxham's  Gag  (%  size). 


instrument,  so  that  when  introduced  into  the  larynx  it  will  conform  to 
the  position  of  the  epiglottis.  The  child,  wrapped  in  a  blanket  or  sheet, 
which  is  pinned  closely  about  the*  neck  so  that  its  arms  are  pinioned, 
should  be  held  in  the  arms  of  the  nurse,  with  its  head  against  her  left 
shoulder.  The  gag  is  then  inserted  between  the  teeth  upon  the  left 
side,  and  intrusted  to  the  assistant  who  is  to  hold  the  head.  The  opera- 
tor's forefinger  of  the  left  hand  should  be  oiled  or  smeared  with  vaseline 
to  prevent  inoculation  through  any  abrasions  upon  the  surface  in  case 


Fig.  115. — Allingham's  Mouth  Gag  (J£  size). 

the  disease  should  prove  to  be  diphtheria,  and  a  broad  metallic  ring  or 
a  rubber  finger  cot  the  end  of  which  has  been  cut  off,  should  be  slipped 
over  the  finger  to  prevent  the  patient  from  biting  it  in  case  the  gag 
should  become  displaced ;  or  in  the  absence  of  these,  the  finger  may  be 
wound  with  a  strip  of  cloth,  which  will  answer  the  purpose  fairly  well. 

The  tube  with  the  applicator,  having  been  dipped  into  warm  water  to 
bring  it  to  blood  heat,  is  ready  for  introduction.  The  child's  head  being 
thrown  slightly  backward  and  held  firmly  by  the  assistant,  the  operator 
introduces  the  forefinger  of  the  left  hand  over  the  base  of  the  tongue, 


420  DISEASES   OF  THE   LARYNX. 

down  behind  the  epiglottis,  until  he  feels  the  arytenoid  cartilage,  upon  the 
upper  edge  of  which  the  finger  is  rested.  The  tube  is  now  guided  down 
along  the  palmar  surface  of  the  finger  until  it  reaches  the  larynx  when, 
the  handle  of  the  applicator  being  elevated  so  as  to  turn  the  end  of  the 
tube  farther  forward,  it  is  passed  into  the  glottis  and  crowded  down- 
ward about  half  an  inch.  At  the  same  time  the  end  of  the  finger  which 
is  resting  on  the  arytenoid  is  brought  upward  and  placed  upon  the 
upper  end  of  the  tube,  which  is  forced  downward  as  far  as  possible. 
The  slide  upon  the  applicator  is  then  shoved  forward,  the  obturator  dis- 
engaged, and  the  applicator  removed,  while  with  the  finger  of  the  left 
hand  the  operator  crowds  the  head  of  the  tube  fairly  into  the  vestibule 
of  the  larynx.  Not  more  than  ten  seconds  should  be  consumed  in  this 
operation :  if  in  this  time  the  operator  does  not  succeed  in  introducing 
the  tube,  it  is  better  to  withdraw  it  and  allow  the  child  to  breathe  for 
a  moment  before  making  another  effort.  As  soon  as  the  tube  is  intro- 
duced, the  child  usually  coughs,  and  the  respiration  generally  has  a. 
peculiar  tubular  sound,  which  indicates  that  the  tube  has  been  placed  in 
the  air  passage;  if  this  sound  is  not  heard,  the  operator  should  feel 
again  for  the  tube  to  ascertain  whether  or  not  it  has  been  passed  into 


Fig.  lit;.—  O'Dwyer's  Extractor  (}  i  size). 


the  oesophagus  instead  of  the  larynx.  If  not  in  proper  position  it  must 
be  withdrawn  by  the  string  and  another  effort  made  to  introduce  it. 
If  in  proper  position,  it  should  he  allowed  to  remain  with  the  string 
attached  for  a  few  minutes  until  respiration  becomes  thoroughly  estab- 
lished and  the  child  has  finished  coughing.  One  of  the  threads  should 
then  be  cut  near  the  lips,  the  operator's  forefinger  carried  down  to 
the  head  of  the  tube  to  hold  it  in  position  and  the  string  withdrawn. 
The  tube  is  left  in  the  larynx,  where  it  should  remain  for  from  two  to 
six  days,  unless  it  should  become  partially  stopped  by  dried  mucus, 
as  indicated  by  difficult  breathing,  or  unless  subsidence  of  the  symp- 
toms leads  us  to  believe  that  the  swelling  has  gone  down  and  the  false 
membrane  disappeared.  In  many  cases  the  tube  will  be  coughed  out  as 
soon  as  the  necessity  for  its  further  use  ceases.  When  it  becomes  nec- 
essary to  remove  it,  the  child  is  placed  in  the  same  position  as  for  its 
introduction,  and  with  the  index  finger  of  the  left  hand  the  operator 
guides  the  extractor  down  to  the  larynx,  where  it  may  be  felt  to 
strike  against  the  end  of  the  tube.  It  is  then  moved  about  gently, 
no  force  being  used,  until  it  drops  into  the  opening  of  the  tube  :  the 
blades  should  then  be  separated  and  firmly  held  while  the  instrument 
and  the  tube  are  being  withdrawn,  especial  care  being  observed  not  to 


MEMBRANOUS   CROUP.  421 

Telax  the  pressure  just  as  the  tube  is  being  turned  out  of  the  pharynx, 
for,  if  this  is  done,  the  instrument  will  slip,  and  the  tube  may  either  fall 
back  into  the  larynx  or  be  swallowed.  It  is  well  to  have  at  hand  a  pair 
of  forceps  for  the  purpose  of  seizing  the  tube  in  case  the  instrument 
should  slip  at  this  stage  of  its  withdrawal.  Special  care  should  be  taken 
that  no  pressure  is  made  upon  the  head  of  the  tube  in  attempting  to 
introduce  the  extractor,  for  the  tube  might  possibly  be  pushed  below 
the  vocal  cords,  an  accident  which  has  happened  in  a  few  cases.  After 
intubation,  mercurials  should  be  given  freely  for  twenty-four  or  forty- 
eight  hours,  as  already  advised,  and  care  should  be  taken  that  when 
the  patient  takes  fluid  none  of  it  passes  into  the  trachea,  an  accident 
liable  to  set  up  pneumonia,  and  one  which  is  probably  responsible 
for  many  of  the  deaths  which  occurred  in  the  early  days  of  intubation. 

When  fluid  of  any  kind  is  taken  while  the  child  is  in  a  sitting 
position,  a  cough  almost  immediately  follows,  indicating  that  some 
of  it  has  passed  into  the  air  passages.  To  avoid  this,  the  most  effec- 
tive plan  is  that  recommended  by  Frank  Gary,  of  Chicago,  and  in- 
troduced by  "Wm.  E.  Casselberry,  which  consists  of  placing  the  pa- 
tient supine  with  the  head  much  lower  than  the  body,  and  feeding 
it  from  a  nursing-bottle  or  through  a  tube.  In  this  position  fluid  can- 
not run  into  the  trachea,  but  will  be  forced  up  the  oesophagus  into 
the  stomach.  Soft  solids  may  be  given  with  the  child  in  any  position, 
and  some  children  will  speedily  learn  to  swallow  even  fluids  in  the  erect 
position;  but  the  friends  must  be  cautioned  not  to  try  this  experiment. 
The  child  may  suck  small  pieces  of  ice  if  it  wishes,  to  quench  thirst,  or 
it  may  be  given  ten  or  fifteen  drops  of  water  without  danger,  even  in 
the  erect  posture,  but  the  safer  way  is  the  better.  Occasionally  on  in- 
troducing the  tube  some  portion  of  the  false  membrane  is  forced  below 
it  in  the  trachea,  and  suffocation  becomes  imminent.  If  this  occurs,  the 
tube  should  be  at  once  withdrawn,  when  it  usually  either  brings  the 
membrane  with  it  or  the  latter  will  be  speedily  coughed  out.  If  this 
should  not  occur,  tracheotomy  should  be  done  at  once.  Because  of  the 
liability  to  this  accident,  the  operator  should  always  have  his  tracheotomy 
instruments  at  hand  when  performing  intubation.  I  consider  the  opera- 
tion of  intubation  preferable  to  tracheotomy  in  croup  occurring  in  chil- 
dren under  five  years  of  age,  and  in  those  older  than  this  it  will  usually 
be  satisfactory;  but  there  are,  all  told,  many  cases  among  these  older 
patients,  especially  in  diphtheritic  laryngitis,  where  tracheotomy  would 
be  advisable. 

Tracheotomy  is  so  thoroughly  described  in  all  works  on  general  sur- 
gery that  I  need  only  mention  the  essential  points  as  they  have  im- 
pressed themselves  upon  me.  The  instruments  which  are  liable  to  be 
needed  are:  a  sharp  pointed  bistoury,  a  scalpel  the  handle  of  which 
should  be  flat  and  thin  so  that  it  may  be  used  in  tearing  through  the 
connective  tissue,  a  blunt  pointed  scalpel  which  may  be  used  in  enlarg- 


422  DISEASES  OF  THE  LARYNX. 

ing  the  opening  in  the  trachea,  three  tenacula,  a  strong  grooved  director, 
an  aneurism  needle,  several  artery  forceps  and  sponge  holders,  several 
large  curved  needles,  and  a  suitable  double  tracheotomy  canula,  which 
should  have  no  fenestra  in  it,  for  such  an  opening  favors  the  forma- 
tion of  granulation  tissue  at  the  upper  end  of  the  incision  in  the  trachea, 
and  is  not  needed.  Two  retractors  are  also  needed  for  holding  apart 
the  edges  of  the  wound,  and  I  like  very  much  a  pair  of  rat-toothed 
artery  forceps  for  taking  up  and  tearing  through  the  connective  tissue. 

The  patient  should  be  placed  upon  a  table  before  a  good  light,  and, 
when  anaesthetized,  a  rolling  pin  wrapped  about  with  a  towel  (or  some 
other  firm  roll)  should  be  placed  under  the  shoulders  and  neck,  in  order 
to  throw  the  head  backward  and  raise  into  j^'ominence  the  anterior 
superior  tracheal  region,  and  give  a  good  field  for  the  operation.  Ether 
or  chloroform  may  be  used  as  a  general  anaesthetic  for  this  operation; 
but  the  latter  is  generally  preferred  especially  for  children.  In  adults 
the  parts  may  be  sufficiently  anaesthetized  by  the  hypodermic  injection 
of  a  few  drops  of  a  four  per  cent  solution  of  cocaine  along  the  line  of 
incision  three  or  four  minutes  before  the  operation  (Form.  140).  The 
operator  stands  at  the  patient's  right,  with  his  right  hand  toward  the 
patient  as  he  faces  the  head,  the  patient  being  between  him  and  the 
light.  The  first  cut  is  made  by  pinching  up  a  transverse  fold  of  the 
skin  over  the  trachea,  transfixing  it  with  the  sharp  pointed  bistoury  and 
cutting  out  so  as  to  make  an  incision  about  two  inches  in  length,  ex- 
tending from  a  little  above  the  inter-clavicular  notch  to  the  cricoid  car- 
tilage. By  this  the  superficial  fascia  and  adipose  tissue  are  exposed, 
which  should  be  worked  through  with  the  back  of  the  scalpel  or  with 
the  aid  of  the  rat-toothed  forceps  and  grooved  director,  accompanied  by 
as  little  cutting  as  possible.  ^Te  then  come  down  iipon  the  dense  fascia 
covering  the  muscles  and  important  blood  vessels.  At  this  stage  of  the 
operation  I  have  derived  great  benefit  from  the  rat-toothed  forceps,  with 
which  I  grasp  the  fascia  and  twist  out  a  small  piece,  thus  making  a  hole 
into  which  the  director  can  be  inserted.  With  the  director,  and  handle 
of  the  scalpel,  the  fascia  can  mostly  be  torn  through,  but  sometimes 
portions  of  it  will  have  to  be  cut  upon  the  grooved  director,  in  doing 
which  great  care  should  be  taken  not  to  incise  a  blood  vessel  which  it 
may  be  difficult  to  detect  when  stretched  over  the  director.  Thus 
working  through  the  fascia  we  come  upon  the  muscles  and  engorged 
blood  vessels,  which  must  be  separated,  by  the  handle  of  the  scalpel, 
the  director,  and  the  finger,  and  pushed  aside,  where  the  assistant 
should  hold  them  by  means  of  the  retractors.  A  thin  layer  of  fascia 
covering  the  trachea  is  thus  exposed;  this  should  be  carefully  divided 
with  the  back  of  the  scalpel  before  the  windpipe  is  opened. 

During  the  operation  blood  should  be  carefully  mopped  away,  and  if 
veins  or  arteries  are  accidentally  cut  they  should  be  caught  by  the 
artery  forceps  and  turned  aside.     In  working  our  way  through  the  soft 


MEMBRANOUS  CROUP.  423 

tissues  down  to  the  trachea,  we  come  upon  the  isthmus  of  the  thyroid,, 
sometimes  found  considerably  enlarged.  This  may  be  crowded  out  of 
the  way  upward  or  downward,  in  either  direction  that  is  most  conven- 
ient, though  upward  is  usually  best.  Sometimes  it  is  so  much  in  the 
way  that  it  is  necessary  to  pass  a  double  ligature,  tie  upon  each  side,  and 
cut  between.  The  ligature  may  be  easily  passed  with  the  aneurism 
needle.  If  we  succeed  in  reaching  the  trachea  without  much  bleeding, 
it  will  be  seen  as  a  round,  yellowish  tube  at  the  bottom  of  the  wound, 
and  may  also  be  readily  felt  by  the  finger.  About  this  time  the  patient 
is  liable  to  cease  breathing,  apparently  from  the  effect  of  the  atmosphere 
on  the  pneumogastric  nerves,  and  it  frequently  becomes  necessary  to 
complete  the  operation  at  once.  However,  if  time  is  allowed,  the  wound 
should  be  sponged  out  and  all  bleeding  checked  before  the  trachea  is 
opened.  From  the  efforts  at  respiration,  the  trachea  often  moves  up 
and  down  convulsively,  and  it  must  be  seized  and  held  firmly  before  an 
incision  can  be  made.  The  best  way  to  accomplish  this  is  to  pass  a 
tenaculum  just  below  the  cricoid  cartilage,  or  first  ring  of  the  trachea, 
and  draw  it  upward  and  forward.  The  point  of  a  scalpel  should  then 
be  passed  between  the  rings  of  the  trachea  at  the  lower  portion  of  the 
wound,  and  a  cut  made  upward,  dividing  three  or  four  rings.  I  prefer 
to  divide  the  third,  fourth,  and  fifth  rings  of  the  trachea  rather  than  to 
make  either  the  high  or  the  very  low  operation,  as  the  high  incision  comes 
too  near  the  larynx,  and  the  very  low  is  more  difficult  because  of  the 
deep  situation  of  the  trachea.  Care  should  be  taken  that  the  point  of 
the  scalpel  does  not  pass  far  enough  through  to  injure  the  posterior  wall 
of  the  trachea.  As  soon  as  the  cut  has  been  made,  air  will  be  heard 
hissing  in  and  out  of  the  trachea,  and  the  knife  should  be  turned  sideways 
to  separate  the  edges,  and  held  a  few  seconds  until  the  patient  obtains  a 
little  air;  but  as  soon  as  possible  the  cut  edges  of  the  trachea  should 
be  caught  with  tenacula  and  the  wound  drawn  open.  The  patient 
then  usually  has  a  paroxysm  of  coughing  that  throws  out  blood,  mucus, 
and  false  membrane,  which  should  be  quickly  wiped  off  so  as  not  to 
be  drawn  back  into  the  opening.  As  soon  as  the  patient  becomes 
quiet,  the  large  bent  needles,  which  have  been  previously  threaded  with 
strong  ligatures,  are  passed,  one  through  each  side  of  the  edges  of  the 
trachea,  the  needle  is  removed,  and  the  threads  are  tied  together  so  as  to 
form  two  loops  by  which  the  trachea  may  be  held  open.  These  are  often 
found  exceedingly  useful  during  the  next  two  or  three  days,  providing- 
the  tube  happens  to  be  displaced,  for  they  relieve  us  from  the  necessity 
of  holding  the  trachea  open,  with  tenacula  or  with  special  instruments 
devised  for  the  purpose,  during  the  reintroduction  of  the  tube;  further- 
more, if  at  any  time  the  tube  should  be  accidentally  displaced,  the  nurser 
by  drawing  upon  these  strings,  may  open  the  wound  so  that  breathing 
can  be  readily  carried  on.  The  tracheal  tube,  which  should  always  be 
as  large  as  can  be  conveniently  worn  by  the  patient,  never  less  than 


424  DISEASES  OF  THE  LARYNX. 

a  quarter  of  an  inch  in  diameter,  may  now  be  introduced,  it  having  first 
l>een  dipped  into  warm  water  to  bring  it  to  the  temperature  of  the  body. 
This  is  a  part  of  the  operation  frequently  found  difficult,  apparently 
either  from  the  surgeon's  having  imperfect  means  of  holding  the  tra- 
cheal wound  open,  or  from  having  only  cut  two  rings  where  an  opening 
through  three  is  necessary.  I  have  never  experienced  any  difficulty 
in  introducing  the  tube,  a  good  fortune  which  I  attribute  to  the  use  of 
the  ligatures  for  holding  the  cut  edges  of  the  trachea  apart  and  to 
making  a  sufficiently  large  opening.  Before  the  operation  is  begun, 
tapes  about  eighteen  inches  in  length  should  be  sewed  to  the  tracheal 
tube;  when  it  has  been  placed  in  the  trachea,  these  are  passed  about 
the  neck  and  tied  upon  one  side  so  as  to  hold  it  firmly  in  place.  In 
case  the  wound  is  too  small,  it  will  not  do  to  try  to  crowd  the  tube 
into  the  trachea,  a  procedure  very  apt  to  force  it  into  the  cellular  tissue 
in  front;  but  the  soft  tissues  should  be  drawn  away  from  the  lower  end 
of  the  wound  and  another  ring  cut,  if  necessary,  to  introduce  the  tube 
easily. 

A  probe-pointed  scalpel  is  generally  used  for  enlarging  the  wound 
and  may  be  employed  for  making  the  main  cut  after  a  slight  puncture 
with  an  ordinary  scalpel;  in  this  way  all  danger  of  cutting  the  pos- 
terior wall  and  opening  through  into  the  oesophagus  may  be  avoided. 
If  the  false  membrane  has  extended  below  the  opening,  before  the  tube 
is  inserted  an  effort  should  be  made  to  remove  all  of  it  that  is  possible 
with  Trousseau's  tracheal  forceps,  or  by  passing  down  into  the  trachea 
a  feather',  or  with  the  forceps  a  strip  of  linen  one  end  of  which  is  held 
by  the  hand,  thus  causing  the  patient  to  cough  and  remove  the  blood 
and  false  membrane.  The  tube  having  been  inserted,  the  wound  above 
and  below  it  may  be  drawn  together  by  one  or  two  stitches  and  covered 
with  a  strip  of  antiseptic  gauze  drawn  under  the  rim  of  the  collar 
of  the  tube  to  prevent  it  from  irritating  the  neck.  A  strij)  of  cloth 
may  then  be  tied  loosely  about  the  neck  and  a  large  piece  of  gauze  folded 
over  it  and  allowed  to  fall  down  over  the  opening  of  the  tube,  thus  pre« 
venting  the  patient  from  coughing  out  blood  or  mucus  upon  the  bed- 
ding and  attendants.  After  the  operation  is  completed,  the  inner  of 
the  two  tracheal  tubes  should  be  removed  and  carefully  cleaned  every 
half-hour,  for  the  first  twenty  four  hours,  in  order  to  prevent  it  from 
filling  with  inspissated  mucus.  Subsequently  it  may  be  cleaned 
less  frequently,  but  it  should  always  be  borne  in  mind  that  it  must  be. 
kept  free.  After  the  operation,  the  temperature  of  the  room  should  be 
kept  at  about  80°  F.  and  the  air  moist.  If  the  secretions  show  a  tendency 
to  dry,  the  patient  may  inhale  from  time  to  time  steam  impregnated 
with  lime,  soda,  or  the  various  other  remedies  already  mentioned.  In- 
ternal administration  of  medicine  calculated  to  prevent  extension  of  the 
false  membrane  should  be  continued  as  before.  The  patients,  even 
when  the  operation  has  been  done  for  diphtheria,  usually  do  exceedingly 


MEMBRANOUS  CROUP.  425 

well  for  twenty-four  or  thirty-six  hours,  and  breathe  so  easily  and  rest 
so  comfortably  that  the  friends  think  a  cure  has  been  effected;  but  at 
the  end  of  this  time  the  development  of  bronchitis  or  pneumonia  or  the 
extension  of  false  membrane  will  often  evince  itself  to  the  physician  by 
increased  fever,  quickened  respiration,  and  renewed  signs  of  imperfect 
aeration  of  the  blood.  When  these  symptoms  occur,  the  disease  usually 
goes  on  from  bad  to  worse  until  death  comes  at  the  end  of  fifty  to 
seventy  hours  after  the  operation.  If  the  case  progresses  favorably,  it 
will  usually  be  found  in  from  five  to  eight  days  that  the  patient  breathes 
easily  "with  the  tube  stopped  by  the  finger,  or  a  cork  which  should  be 
worn  some  hours  before  an  attempt  is  made  to  remove  the  canula. 
When  this  is  removed,  the  sides  of  the  wound,  as  a  rule,  readily  fall  to- 
gether, and  within  a  few  hours  no  air  will  pass  through  the  opening.  If 
the  wound  does  not  speedily  close,  all  that  is  usually  necessary  is  to 
touch  it  a  few  times  with  the  solid  silver  nitrate.  Sometimes,  after 
the  tracheal  canula  has  been  worn  for  months,  it  is  found  on  attempting 
its  removal  that  the  patient  cannot  breathe,  by  reason  of  spasm  of  the 
glottis  or  an  obstruction  from  new  growths  at  the  upper  part  of  the 
wound.  If  granulation  tissue  is  found  in  the  trachea,  it  must  be 
removed  before  a  cure  can  be  effected,  but  to  overcome  the  tendency  to 
spasm,  no  method  has  yet  been  found  so  satisfactory  as  the  introduction 
of  an  O'Dwyer  tube,  which  will  generally  be  coughed  out,  or  may  be 
removed  within  forty-eight  hours,  and  may  not  be  needed  afterward.. 
When  a  tracheal  canula  has  been  worn  long,  it  often  becomes  necessary, 
especially  in  a  thin  subject,  to  make  a  plastic  operation  in  order  to  cover 
the  tracheal  wound.  This  may  be  best  done  by  paring  the  edges  of  the 
tracheal  wound,  loosening  up  the  soft  coverings  freely  on  each  side,  then 
drawing  them  forward  and  stitching  the  edges  together.  In  performing 
tracheotomy,  chloroform  is  preferable  to  ether  as  an  anaesthetic,  because 
of  the  profuse  secretion  excited  by  the  latter,  and  it  is  probable  that  in 
these  cases  it  is  quite  as  safe.  W'hen  carbonic  acid  poisoning  is  pro- 
nounced, no  anaesthetic  is  needed,  but  at  other  times  anaesthesia  is  im- 
portant, not  alone  for  prevention  of  pain,  but  to  keep  the  patient  quiet. 
In  adults  who  are  not  timid,  and  in  some  children,  local  anaesthesia, 
quite  sufficient,  may  be  obtained  by  injecting  under  the  skin  along  the 
line  of  incision  a  few  drops  of  a  weak  solution  of  cocaine  (Form.  140). 

Eapid  Tracheotomy. — In  extreme  cases  it  sometimes  becomes  im- 
perative to  open  the  trachea  at  once;  for  this  purpose  various  instru- 
ments have  been  devised.  Some  surgeons  recommend  that  the  child 
be  placed  upon  its  face  at  the  side  of  the  table,  the  trachea  steadied 
with  the  thumb  and  finger  of  the  left  hand,  and  the  skin,  fascia,  muscles, 
blood  vessels,  and  tracheal  walls  divided  with  a  single  cut.  This  proced- 
ure has  also  been  recommended  for  ordinary  cases  in  place  of  the  care- 
ful dissection  generally  practised,  but  the  danger  of  hemorrhage  renders 
it  extremely  objectionable  except  in  those  very  rare  cases  where  not  a 


*"26  DISEASES   OF  THE  LARYNX. 

second  can  be  lost,  and  an  intubation  set  is  not  at  hand.  Hook-like 
traclieotomes  consisting  of  blades  that  may  be  opened  after  the  trachea 
has  been  perforated,  and  which  will  Mms  cut  a  sufficiently  large  opening 
to  introduce  the  tracheal  tube,  have  also  been  recommended,  but  they 
do  not  meet  with  favor  among  surgeons.  An  ingenious  trocar  which 
enables  the  operator  to  leave  the  canula  in  the  trachea  has  been  devised, 
but  the  canula  is  too  small,  and  I  consider  it  a  dangerous  instrument, 
which  is  likely  to  cause  the  loss  of  valuable  time,  if  not  of  the  patient's 
life.  By  most  experienced  surgeons,  tracheotomy  is  considered  a  very 
dangerous  operation,  because,  with  the  greatest  care,  serious  hemorrhage 
will  sometimes  be  encountered,  and  unavoidable  accidents  may  so  delay 
the  operation  that  breathing  ceases  before  it  is  completed,  and  it  may 
become  necessary  to  open  the  trachea  hastily  before  the  superficial  tis- 
sues have  been  cleared  away.  For  the  avoidance  of  hemorrhage,  great 
care  should  be  exercised  in  tearing  instead  of  cutting  through  the  super- 
ficial tissues,  and  if  by  accident  a  blood  vessel  is  opened  it  should  be 
caught  immediately  with  artery  forceps,  and  if  large  it  should  subse- 
quently be  tied  and  the  ligature  cut  short;  if  small,  it  may  be  twisted 
sufficiently  to  prevent  hemorrhage.  If  during  the  operation  the  patient 
stops  breathing,  at  least  five  or  ten  seconds  may  be  safely  consumed  in 
opening  the  trachea,  providing  artificial  respiration  is  then  established ; 
therefore  the  surgeon  should  not  be  precipitate  in  his  incision.  In  these 
cases  the  surgeon  will  sometimes  be  able,  by  keeping  up  artificial  respi- 
ration, to  restore  a  child  apparently  dead  for  fifteen  or  twenty  minutes. 
There  is  danger  from  gradual  oozing  of  blood  into  the  tracheal  wound 
after  the  tube  has  been  introduced,  but  usually  this  is  stopped  by 
the  introduction  of  a  tracheal  canula.  Secondary  hemorrhage  some- 
times occurs;  if  it  takes  place,  the  canula  must  be  removed  and  the 
bleeding  vessels  tied  or  twisted.  The  danger  from  the  extension  of  the 
disease  to  the  lower  air  passages,  and  the  development  of  bronchitis  or 
pneumonitis,  cannot  always  be  anticipated,  but  it  is  best  guarded  against 
by  care  to  prevent  the  entrance  of  blood  or  other  foreign  substance 
into  the  air  passages,  by  keeping  the  atmosphere  of  the  room  warm  and 
moist  and  by  the  judicious  administration  of  internal  remedies.  The 
tracheal  canula  is  not  infrequently  coughed  out;  this  is  best  prevented 
by  having  a  long  tube  which  will  pass  into  the  trachea  three-quarters  of 
an  inch  beyond  the  cut.  Many  patients  have  been  lost  because  of  secre- 
tions collecting  and  drying  in  the  tube;  this  can  only  be  obviated  by 
carefully  and  frequently  cleansing  the  inner  tube.  A  tracheotomized 
patient  must  be  left  in  the  care  of  the  best  possible  nurse,  and  every 
detail  should  be  carefully  watched  by  the  physician  until  all  danger  is 
passed.  The  prognosis  should  always  be  guarded  until  convalescence  is 
fully  established. 


CHAPTER  XXY. 

DISEASES    OF   THE   LAEYNX.— Continued. 

PHLEGMONOUS  LARYNGITIS. 

Synonyms. — Submucous  laryngitis,  diffuse  abscess  of  the  larynx, 
laryngitis  phlegrnonosa,  laryngitis  submucosa  purulenta,  laryngitis 
sero-purulenta. 

Phlegmonous  laryngitis  is  a  rare  affection,  in  which  inflammation 
attacks  the  submucous  tissues,  causing  suppuration  and  necrosis,  with 
the  formation  of  diffused  or  circumscribed  abscesses  which  are  generally 
located  in  the  upper  portion  of  the  larynx  at  the  base  of  the  epiglottis, 
or  in  the  aryteno-epiglottidean  folds.  The  affection  sometimes  involves 
the  ventricular  bands,  and  rarely  the  vocal  cords. 

Etiology.- — -The  disease  may  either  originate  in  the  larynx  or  extend 
to  it  from  the  surrounding  parts,  especially  from  the  pharynx,  in  which 
case  it  is  nearly  always  due  to  blood  poisoning.  In  many  instances  the 
inflammation  begins  in  the  cartilages  or  perichondrium,  usually  result- 
ing in  such  cases  from  typhoid  fever  or  syphilis,  or  occasionally  from 
other  diseases. 

Symptomatology. — At  first  the  patient  often  complains  of  a  sensa- 
tion as  of  some  foreign  substance  in  the  part,  soon  followed  by  actual  pain, 
especially  upon  deglutition.  The  voice  becomes  weak  or  hoarse  and 
may  finally  be  lost,  and,  as  the  swelling  advances,  dyspnoea  occurs,  which 
in  severe  cases  gradually  increases,  causing  stridulous  respiration,  or 
orthopncea,  cyanosis,  and  all  the  symptoms  of  strangulation.  There  are 
frequent  violent  efforts  to  clear  the  throat,  but  usually  no  cough.  Dys- 
phagia is  more  or  less  prominent  in  proportion  to  the  swelling  of  the 
epiglottis  which  may  often  be  detected  by  palpation,  but  this  should  be 
practised  carefully  as  there  is  danger  of  exciting  suffocative  spasm  of 
the  cords.  Upon  inspection,  the  parts  are  found  deeply  congested  aud 
much  swollen,  and  often  the  tracheal  mucous  membrane  is  involved. 
In  some  cases  swelling  and  fluctuation  are  present. 

Diagnosis. — In  adults  this  may  be  easy  from  the  history  of  ante- 
cedent disease,  with  gradually  increasing  dyspnoea,  and  from  the  appear- 
ance of  the  parts  on  laryngoscopic  examination.  But  in  children  when 
the  larynx  cannot  be  inspected  there  is  some  danger  of  confounding  it 
with  laryngismus  stridulus,  laryngeal  polypus,  retro-pharyngeal  abscess, 
foreign  bodies  in  the  larynx,  or  diphtheritic  laryngitis.     We  may  exclude 


428  DISEASES  OF  THE  LARYNX. 

retro-pharyngeal  abscess  by  inspecting  the  fauces  and  by  lifting  the 
larynx,  which  will  relieve  the  dyspnoea  in  most  cases  of  abscess  of  the 
pharynx,  but  not  in  phlegmonous  laryngitis. 

A  history  of  their  entrance  and  absence  of  antecedent  disease  may 
readily  distinguish  foreign  bodies.  Compared  with  phlegmonous  laryn- 
gitis, polypus  develops  much  more  slowly,  and  laryngismus  stridulus 
much  more  cpiickly,  and  neither  of  them  is  attended  by  the  symptoms 
of  inflammation. 

Prognosis. — The  disease  usually  runs  a  rapid  course  and  terminates 
fatally  in  about  seventy-five  j:>er  cent  of  the  cases,  from  either  suffoca- 
tion or  exhaustion. 

Treatment. — Early  in  the  disease  the  best  remedies  are  leeches  and 
warm  applications  to  the  neck,  with  steam  inhalations,  or,  instead  of 
these,  constant  sucking  of  bits  of  ice.  As  soon  as  there  is  oedema  or  a 
collection  of  pus,  scarification  should  be  employed.  Quinine  and  strych- 
nine in  medium  doses  and  potassium  chlorate  in  full  doses  are  indicated, 
together  with  nourishing  diet  and  the  free  use  of  stimulants.  Remedies 
and  food  should  be  given  by  enema  if  the  patient  cannot  swallow. 
Urgent  dyspnoea  demands  intubation  or  tracheotomy,  the  latter  gener- 
ally being  most  efficient  in  this  disease. 

ERYSIPELATOUS   LARYNGITIS. 

Erysipelatous  laryngitis  is  an  inflammation  of  the  larynx,  usually 
associated  with  erysipelas  of  the  tongue  and  palate.  Most  cases  are 
either  endemic  or  epidemic.  It  sometimes  results  from  metastasis  of 
cutaneous  erysipelas,  or  from  its  extension  along  the  mucous  membrane 
of  the  nose,  mouth,  or  ear.  The  inflammation  soon  terminates  in  ex- 
tensive suppuration  and  sloughing  of  the  intra-laryngeal  or  perilaryn- 
geal tissues. 

Etiology. — The  pharynx  is  usually  first  involved,  the  disease  sub- 
sequently extending  into  the  larynx. 

Symptomatology. — The  symptoms  are  fever,  local  pain  and  swell- 
ing, with  difficulty  in  speaking,  dyspnoea,  and  great  prostration.  In 
severe  cases  these  symptoms  are  usually  succeeded  by  vomiting  and 
finally  by  delirium.  Early  in  the  disease  the  laryngoscopic  appearances 
are  simply  those  of  laryngitis;  subsecjuently  sloughs  or  extensive  ulcers 
will  be  observed. 

Diagnosis. — The  diagnosis  must  be  bused  upon  the  symptoms  and 
the  evidence  of  inflammation  of  the  same  type  affecting  the  skin  or  the 
mucous  membrane  of  the  mouth. 

Prognosis. — The  disease  usually  runs  a  rapid  course,  terminating 
fatally  in  the  majority  of  cases.  According  to  Cornil  {Archives  generales 
de  Medicine,  Paris,  1S62)  about  one-fourth  of  those  cases  die  in  which 
the  inflammation  first  begins  in  the  larynx,  whereas  of  those  in  which 


ABSCESS   OF  THE  LARYNX.  429 

the  inflammation  extends  from  the  pharynx  to  the  larynx  about  three- 
fourths  die.  This  result  is  apparently  due  to  an  increase  in  the  consti- 
tutional disease  marked  by  extension  of  the  inflammation  from  the 
pharynx  downward. 

Treatment. — The  general  treatment  should  be  the  same  as  for  ery- 
sipelas of  other  localities.  Quinine  and  tincture  of  iron  are  most  useful 
medicines.  Xourishing  diet  is  essential,  and  stimulants  are  indicated 
early.  In  view  of  the  more  recent  bacteriological  knowledge  concern- 
ing the  materies  morbi  of  erysipelas,  agents  opposing  the  development 
of  micro-organisms  are  indicated;  therefore  a  saturated  boric  acid 
spray,  and  salol  and  naphthalin  internally,  are  recommended.  Shoe- 
maker, in  his  late  work,  praises  pilocarpine  highly,  regarding  it  as  almost 
a  specific  in  the  cutaneous  erysipelas.  In  hopes  of  aborting  the  attack, 
ice  may  be  sucked  constantly  for  the  first  few  hours.  Gibb  reports  a 
case  in  which  applications  of  a  strong  solution  of  silver  nitrate,  gr.  lxxx. 
ad  3  i.,  every  six  hours  cut  short  the  disease.  Steam  inhalations  and 
anodynes  will  be  useful  in  relieving  pain.  Tracheotomy  will  naturally 
suggest  itself,  but  it  is  of  doubtful  value.     Intubation  mav  be  tried. 


ABSCESS   OF   THE   LARYZnX. 

Abscess  of  the  larynx  consists  of  a  circumscribed  collection  of  pus 
in  the  soft  tissues.  It  is  very  rarely  a  primary  affection,  but  occurs  not 
infrequently  as  the  result  of   inflammation  of  the  cartilages   or  peri- 


I 

Fig.  117. — Perichondritis  and  Abscess  of  T,at?vvt, 

chondrium  following  typhoid  fever  or  pyaemia,  or  dependent  upon 
tuberculosis,  syphilis,  or  local  injuries.  Abscesses  occurring  as  the  re- 
sult of  typhoid  fever  are  generally  found  during  the  second  or  third 
week  of  the  fever.  The  smaller  of  these  appear  just  beneath  the 
mucous  membrane,  and  the  larger  ones  beneath  the  perichondrium. 

Symptomatology. — The  symptoms  of  abscess  of  the  larynx  are: 
pain  which  is  aggravated  by  pressure,  cough,  dysphonia  or  aphonia, 
difficulty  in  swallowing,  and  dyspnoea.  Upon  laryngoscopic  examina- 
tion, the  abscess  appears  as  a  glistening  swelling,  red  at  its  base,  and 
either  red  or  yellowish  at  its  apex.     It  is  usually  located  on  the  inner 


430  DISEASES  OF  THE  LARYNX. 

surface  of  the  larynx,  either  at  the  base  of  the  epiglottis,  upon  the  aryt- 
enoid or  supra-arytenoid  cartilages,  or  in  the  aryteno-epiglottidean  folds. 

Diagnosis. — In  children  the  disease  may  be  mistaken  for  croup  or 
retro-pharyngeal  abscess,  and  the  diagnosis  is  sometimes  attended  with 
great  difficulty.  In  adults  the  luryngoscopic  appearances  are  character- 
istic if  the  abscess  points;  otherwise  it  is  not  always  possible  to  distin- 
guish it  from  simple  inflammatory  swelling. 

It  is  distinguished  from  croup  by  the  history,  pain,  and  difficulty  in 
deglutition;  from  retro-pliaryngeal  abscess  by  inspection  and  palpation 
of  the  pharynx;  from  acute  catarrhal  inflammation  by  the  history,  local- 
ized inflammation  and  swelling;  from  oedema  by  the  history,  symptoms, 
and  signs;  oedema  follows  renal  or  cardiac  disease  instead  of  inflamma- 
tion of  the  cartilages  and  perichondrium,  and  it  is  characterized  by  a 
pale,  translucent  color,  and  the  absence  of  pain  and  dysphagia. 

Prognosis. — The  affection  usually  terminates  in  from  three  days  to 
two  weeks  and  if  seen  in  time  and  properly  treated,  most  cases  recover. 


Fig.  118.— Infra-glottic  Abscess  of  Larynx,  Fig.  119.— The  Same  as  Fig.  118,  Twelve  Hours 

due  to  Syphilis.    Great  dyspnoea.  after  Opening  of  Abscess. 

Sometimes  fistulous  openings  remain  after  opening  of  the  abscess  into 
the  oesophagus  or  externally;  and  in  the  former  case  liquids  or  soft  food 
are  apt  to  pass  into  the  larynx  during  deglutition,  causing  dangerous 
spasms  or  pneumonia.  In  some  cases  subcutaneous  emphysema  has 
resulted.  When  the  affection  proves  fatal,  death  may  occur  from  suffo- 
cation or  the  exhaustion  attending  prolonged  suppuration. 

Treatment. — When  the  abscess  can  be  reached,  the  pus  should  be 
evacuated  by  means  of  the  laryngeal  lancet.  When  this  cannot  be  ac- 
complished, the  patient  must  be  carefully  watched,  and  if  dyspnoea 
threatens,  tracheotomy  must  be  performed.  Subsequently,  with  the 
trachea  completely  stopped  by  a  large  canula,  renewed  efforts  should  be 
made  to  open  the  abscess. 

(EDEMA  OF  THE  LARYNX. 

Synonyms. — (Edematous  laryngitis,  sub-mucous  laryngitis,  supra- 
glottic  or  infra-glottic  dropsy,  oedema  glottidis. 

(Edema  of  the  larynx  consists  of  a  serous  or  sero-sanguinolent  infil- 
tration into  the  areolar  tissue  beneath  the  mucous  membrane,  which, 
owing  to  the  formation  of  the  parts,  at  once  diminishes  the  size  of  the 


(EDEMA   OF  THE  LARYNX.  431 

air  tube,  causing  dyspnoea,  and  unless  the  process  is  checked  or  promptly 
relieved,  speedily  inducing  suffocation. 

When  the  infiltration  is  of  a  sero-purulent  character,  the  affection  would 
more  properly  come  under  the  head  of  phlegmonous  laryngitis. 

A  spasmodic  element  frequently  coexists  with  the  mechanical  inter- 
ference to  respiration,  and  thus  adds  greatly  to  the  gravity  of  the  case. 

Etiology. — The  trouble  may  result  from  simple  acute  catarrhal  in- 
flammation, but  most  frequently  from  tuberculosis,  syphilis,  or  Bright's 
disease.  It  is  sometimes  induced  by  exposure  to  impure  atmosphere, 
sewer  gas,  and  the  like,  or  by  inhalation  of  extremely  cold  air;  it  may 
follow  injuries  from  foreign  bodies  and  operative  procedures  or  scalds 
and  burns.  It  occasionally  follows  small-pox,  typhoid  fever,  and  scarla- 
tina, or  results  from  submucous  hemorrhage,  from  erysipelas,  or  from 
chronic  inflammation  of  the  cervical  tissues,  and  sometimes  from  the 
pressure  of  aneurisms  of  the  larger  arteries. 

Symptomatology. — There  is  usually  a  history  of  extreme  fatigue, 
exposure  to  excessive  heat  or  cold,  an  injury  to  the  larynx,  or  of  some  of 
the  diseases  already  mentioned.  The  acute  attack  not  infrequently 
comes  on  suddenly  during  the  night,  the  patient  awaking  with  a  sense 
of  discomfort  in  the  throat,  or  choking.  The  symptoms  increase  in  se- 
verity with  great  rapidity,  giving  rise  to  frequent  suffocative  attacks, 
with  intervals  of  less  impeded  respiration.  These  intervals  grow  shorter 
and  shorter  until  relief  is  obtained  or  death  occurs.  When  oedema  fol- 
lows chronic  diseases,  the  progress  of  the  case  is  more  gradual.  At  first, 
symptoms  due  to  slight  obstruction  present  themselves.  These  gradu- 
ally increase  in  severity,  until  finally  a  suffocative  paroxysm  occurs, 
which  usually  subsides  after  a  short  time,  to  recur  after  a  few  hours  and 
again  and  again  at  shorter  intervals,  until  it  proves  fatal.  The  symp- 
toms referable  to  the  larynx  are  slight  local  tenderness,  with  a  sense  of 
dryness,  heat,  and  constriction  in  the  throat,  hoarseness,  aphonia,  dysp- 
noea with  labored  and  sometimes  stridulous  respiration,  and  more  or 
less  difficulty  in  swallowing.  The  inspiratory  act  is  chiefly  obstructed, 
expiration  being  comparatively  free;  this  is  an  important  point  in  the 
diagnosis.  Upon  inspection,  the  fauces  are  sometimes,  found  to  be 
oedematous;  and  by  the  aid  of  the  laryngoscope  the  epiglottis,  or  aryteno- 
epiglottidean  folds,  or  both,  are  seen  to  be  greatly  swollen,  and  occasion- 
ally the  ventricular  bands  or  vocal  cords  are  also  affected.  The  affected 
parts  are  translucent,  of  a  pinkish  or  yellowish  color,  and  closely  resem- 
ble, in  their  general  appearance,  an  oedematous  eyelid  or  prepuce.  The 
epiglottis  has  the  appearance  of  a  roll  or  ridge,  and  the  aryteno-epiglot- 
tidean  folds  are  globular  or  irregular  in  form,  and  usually  project  upon 
both  sides;  though  occasionally  only  one  side  is  involved,  and  at  other 
times  the  swelling  is  greater  on  one  side  than  on  the  other.  When 
oedema  results  from  catarrhal  inflammation,  the  vocal  cords  are  always 


432 


DISEASES   <>F  THE  LARYNX. 


of  a  bright  red  color,  and  the  other  parts  even  more  congested,  some- 
times showing  distended  veins  upon  the  surface.  When  resulting  from 
renal,  hepatic,  or  cardiac  disease,  the  membrane  is  pale  and  translucent. 
In  hemorrhagic  effusion  there  is  localized  swelling  of  a  deep  red  color. 
When  occurring  during  scarlet  fever,  the  mucous  membrane  is  apt  to  be 
congested  in  patches  of  varying  shades.  In  typhus  fever  the  (Edema- 
tous larynx  is  usually  of  a  dusky  red  hue.  When  inflammation  has  been 
excited  by  irritant  poisons,  excoriations  of  the  epiglottis  can  frequently 
be  detected;  when  caused  by  scalds,  patches  of  thin  false  membrane 
are  observed:  and  when  by  other  traumatic  causes  intense  congestion  be- 
ginning at  the  seat  of  injury  is  generally  present. 

Prognosis. — "Most  cases  terminate  within  five  or  ten  days,  but  some 
are  more  prolonged.     About  fifty  per  cent  of  all  these  cases  prove  fatal. 


Fm.  liO. — (Edema  of  Larynx  (Cohen). 

(Edema  caused  by  pharyngeal  inflammation  usually  terminates  favora- 
bly, but  when  resulting  from  inflammation  of  the  cervical  tissues  it  is 
generally  fatal.  In  oedema  of  the  larynx  resulting  from  syphilis,  the 
prognosis  is  fairly  favorable  if  proper  treatment  is  adopted.  Tuber- 
cular cases  ultimately  end  in  death,  and  those  due  to  blood  poisoning 
are  nearly  always  fatal. 

Treatment. — Prompt  and  complete  relief  is  sometimes  given  by  the 
administration  of  pilocarpine  hydrochlorate  which  may  be  used  hypo- 
dermically  in  doses  of  gr.  £.  It  will  cause  profuse  salivation  or  dia- 
phoresis, or  both,  in  about  twenty  minutes.  Larger  doses  cause  a  pro- 
fuse and  prostrating  diaphoresis.  Its  depressant  effect  upon  the  cardiac 
muscle  should  always  be  borne  in  mind:  and  when  oedema  of  the  larynx 
attends  heart  disease,  or  when  the  heart  is  weakened  from  other  causes, 
this  remedy  should  be  exhibited  with  much  care.  It  often  causes  vomit- 
ing after  two  or  three  hours,  but  this  action  is  also  favorable  in  (edema 
of  the  larynx.  If  we  fail  with  the  remedy,  scarification  of  the  larynx  is 
the  best  treatment:  when  this  does  not  afford  relief,  tracheotomy  or  in- 
tubation must  be  performi 


CHONDRITIS  AND  PERICHONDRITIS.  433 

Chronic  03d ema  of  the  larynx  should  be  treated  by  scarification,  fol- 
lowed by  the  stronger  stimulating  or  astringent  pigments,  as  zinc  chlor- 
ide or  silver  nitrate.  When  the  oedema  is  located  below  the  vocal  cords, 
very  little  can  be  accomplished  by  topical  applications.  Schlatter's 
method  of  dilating  the  larynx  by  means  of  hard  rubber  tubes  of  gradu- 
ally increasing  size,  which  are  introduced  every  day  or  second  day,  and 
kept  in  positiou  several  seconds  or  as  much  longer  as  the  patient  can 
tolerate  them,  has  been  successfully  employed  in  cases  of  this  kind;  but 
from  the  limited  experience  of  the  past  few  years,  dilatation  by  O'Dwyer's 
laryngeal  tubes  seems  the  most  satisfactory  for  the  majority  of  cases. 
If  dyspnoea  cannot  be  relieved  by  these  methods  tracheotomy  must  be 
performed. 

CHONDRITIS   AND  PERICHONDRITIS   OF  THE   LARYNGEAL 

CARTILAGES. 

An  inflammation  of  the  laryngeal  cartilages  or  perichondrium  seldom 
occurs  as  a  primary  affection.  The  acute  disease  is  seldom  found  except 
in  persons  of  advanced  life.  The  inflammation  soon  results  in  more  or 
less  caries  of  the  cartilages  and  thickening  of  the  remaining  portions. 
In  severe  cases  the  whole  cartilage  may  be  destroyed  and  thrown  off. 

Etiology. — The  disease,  sometimes  primary,  is  usually  the  result  of 
tuberculosis,  syphilis,  typhoid  fever,  or  of  trauma.  It  has  been  produced 
by  injury  done  in  laryngeal  operations,  by  external  wounds,  and  in  rare 
instances  when  the  cricoid  cartilage  is  ossified,  by  introduction  of  the 
oesophageal  sound. 

Symptomatology. — Excepting  in  traumatic  cases,  the  patient  usu- 
ally first  complains  of  tenderness  and  pain  in  the  larynx,  soon  followed 
by  hoarseness  and  more  or  less  dyspnoea  and  difficulty  in  swallowing. 
The  crico-arytenoid  articulations  are  early  affected,  and  as  a  result  there 
is  partial  or  complete  immobility  of  the  vocal  cords.  Finally,  especially 
after  typhoid  fever,  the  consolidation  and  contraction  of  the  inflamma- 
tory lymph  may  cause  permanent  anchylosis  of  this  joint.  Occasionally 
a  grating  or  crepitating  sensation  may  be  detected  on  palpation.  Until 
an  abscess  forms,  laryngoscopic  examination  will  often  reveal  nothing 
except  slight  hyperaemia,  with  very  trifling  swelling  of  the  parts. 

inflammation  of  the  thyroid  cartilage  causes  some  tumefaction  of  the 
ventricular  bands  and  of  the  arytenoid  or  crico-arytenoid  articulations, 
impairment  of  the  movement  of  the  vocal  cords  and  occasionally  subglottic 
swelling.  Inflammation  of  the  cricoid  cartilage  causes  swelling  below 
the  vocal  cords,  which  may  not  be  detected  at  first,  but  as  the  disease 
goes  on  to  suppuration  the  tumefaction  becomes  more  prominent  and 
sometimes  a  yellowish  spot  may  be  seen  as  the  abscess  is  about  to  open. 
Abscesses  of  the  arytenoids  present  above  and  those  of  the  cricoid  just 
below  the  glottis.  Abscesses  of  the  thyroid  cartilage  usually  point  below 
28 


4:J4:  DISEASES   OF  THE  LARYNX. 

the  glottis,  but  sometimes  externally.  When  the  affection  is  secondary, 
ulceration  of  the  mucous  membrane  may  sometimes  be  first  detected, 
extension  of  which  finally  causes  inflammation  of  the  cartilage  or  peri- 
chondrium. 

Diagnosis. — Primary  perichondritis  may  be  suspected  when  the  pa- 
tient complains  of  dull  aching  or  boring  pain,  and  laryngoscopy  exam- 
ination reveals  enlargement  of  some  of  the  cartilages  without  much 
congestion  of  the  parts.  Secondary  perichondritis  may  escape  notice 
owing  to  swelling  of  the  parts.  Late  in  the  affection  abscesses  are 
formed,  the  movements  of  the  vocal  cords  become  impaired,  distortion 
of  the  larynx  may  occur  without  the  presence  of  cicatricial  tissue,  and 
often  a  fetid  discharge  takes  place.  From  a  consideration  of  these  con- 
ditions and  the  history,  the  affection  can  generally  be  easily  distin- 
guished from  other  laryngeal  diseases. 

Prognosis. — The  majority  of  cases  prove  fatal.  Cases  have  occurred, 
however,  in  which  the  whole  arytenoid  or  even  cricoid  cartilages  have 
been  thrown  off,  and  recovery  has  taken  place.  Usually  gradual  exten- 
sion of  the  disease  produces  progressive  dyspnoea,  or  the  rapid  formation 
of  an  abscess  ma}'  cause  sudden  suffocation  unless  tracheotomy  is  per- 
formed. When  an  abscess  ruptures,  pus  may  escape  externally  or  into 
the  oesophagus  or  larynx,  and  the  continued  discharge  may  finally  ex- 
haust the  patient's  strength.  Tracheotomy  may  be  performed  to  avert 
suffocation;  but  if  recovery  takes  place,  it  is  probable  that  the  patient 
will  have  to  wear  the  tracheal  canula  during  the  remainder  of  life. 
Even  after  tracheotomy  there  are  but  few  who  live  longer  than  twelve 
or  eighteen  months,  but  those  in  whom  the  disease  is  not  of  specific  or 
tubercular  origin  may  live  many  years. 

Treatment. — When  the  disease  is  slowly  progressing,  the  patient's 
general  condition  demands  our  first  attention.  In  specific  cases  the 
iodides  in  large  doses  are  of  the  most  importance,  and  in  all  cases  tonics 
and  nutritious  diet  are  usually  necessary.  Tracheotomy  must  be  per- 
formed when  dyspnoea  becomes  marked,  and  the  lower  operation  will  be 
most  likely  to  prolong  life.  If  the  patient  recovers,  subsequent  attempts 
at  dilatation  of  the  larynx,  either  by  Schrotter's  dilators  or  by  O'Dwyer's 
tubes,  should  be  made,  and  will  sometimes  be  successful.  A  fistulous 
communication  between  the  larynx  and  the  oesophagus  demands  feeding 
by  the  oesophageal  tube.  Occasionally  nutritive  enemata  must  be  em- 
ployed. 

TUBERCULAR   LARYNGITIS. 

Synonyms. — Laryngeal  phthisis,  throat  consumption,  helcosis  laryn- 
gis,  laryngeal  tuberculosis. 

Tubercular  laryngitis  is  a  chronic  affection  of  the  throat  attended  by 
dyspnoea,  dysphagia,  emaciation,  and  hectic  fever.  It  is  characterized 
by  moderate  congestion  and  swelling  of  various  portions  of  the  larynx 


TUBERCULAR  LARYNGITIS. 


435 


followed  by  ulceration  and  severe  pain  on  attempts  at  swallowing,  and 
usually  by  a  peculiar  pyriform  swelling  of  one  or  both  arytenoids  or 
ary-epiglottic  folds;  which  is  often  pathognomonic. 

Anatomical  and  Pathological  Chaeacteristics. — The  charac- 
teristics vary  considerably  in  different  cases  and  at  different  times  in 
the  same  case.  Early  in  the  attack  there  is  sometimes  simple  conges- 
tion, but  more  frequently  anasmia.     Ere  long  in  most  cases  swelling  of 


Fig.  121.— Tubercular  Laryngitis. 


Fig.  122. — Tubercular  Laryngitis,  showing 
Pyriform  Swelling  of  Left  Ary-Epiglottic 
Fold  and  Paresis  of  Left  Vocal  Cord. 


the  soft  tissues  over  the  arytenoids  from  tubercular  infiltration  gives 
rise  to  the  pyriform  appearance.  This  swelling  may  occur  on  one  or 
both  sides,  and  the  epiglottis  may  also  be  much  swollen  or,  in  rare  in- 
stances, it  may  be  thickened  while  the  arytenoids  remain  normal. 
Shortly  afterward,  at  about  the  time  this  swelling  takes  place,  ulcers 
usually  occur  on  the  cords  or  the  ventricular  bands,  and  they  may 
subsequently  be  found  in  the  upper  portions  of  the  larynx.  Ulcera- 
tion  in   this   disease   nearly  always  begins   in   the  lower  part  of   the 


TTMnW^THTTlUmT,,^ 


Fig.  123.  —  Tubercular  Laryngitis,  showing 
Pyriform  Swelling  of  Both  Ary-Epiglottic 
Folds  and  Thickening  of  Epiglottis. 


Fig.  124.— Tubercular  Laryngitis. 


larynx,  subsequently  extending  upward  to  involve  the  arytenoids,  the 
posterior  commissure  and  the  epiglottis.  The  ulcers  are  superficial  and 
at  first  small;  later  these  may  coalesce,  forming  large,  irregular  patches, 
and  they  may  attain  considerable  depth  when  the  cartilages  are  involved. 
Occasionally  the  tubercular  deposit  may  be  detected  before  ulceration 
has  taken  place  ;  these  macroscopic  deposits  consist  of  small,  yellowish 
or  grayish  granules  not  larger  than  a  millet  seed  or  a  pin's  head.  Not 
more  than  two  or  three  of  these  are  likely  to  be  detected,  but  they  are 
sometimes  found  in  groups.  It  is  probable  that  in  most  cases  these 
immediately  precede  the  ulceration.  Warty  growths  are  sometimes 
found  about  the  edges  of  the  ulcer  or  upon  its  surface;  these  are  soft, 


436  DISEASES  OF  THE  LARYNX 

easily  broken  down,  and  have  somewhat  the  appearance  of  papillo- 
mata  (Figs.  125,  12G).  Bosworth  describes  as  one  of  the  phases  of  the 
the  disease  an  acute  follicular  inflammation  of  the  epiglottis  which  may 
extend  to  other  portions  of  the  larynx.  This  is  characterized  by  con- 
gestion and  swelling  of  the  mucous  membrane,  with  numerous  pearly 
white  or  gray  granulations  upon  its  surface,  which  at  first  appear  like 
the  follicles  in  follicular  tonsillitis,  except  that  they  are  smaller.  After  a 
short  time  they  rupture,  coalesce,  and  form  superficial  ulcers.  In  this 
way  the  entire  epiglottis  may  become  implicated.  In  such  cases  the 
patient  is  almost  unable  to  swallow  on  account  of  the  severe  pain,  and 
as  a  result  he  declines  rapidly,  and  may  die  within  two  or  three  weeks. 
Tubercular  deposit  and  ulceration  frequently  affect  the  perichondrium 
or  the  cartilages.  If  the  latter  are  affected,  necrosis  and  extensive  sup- 
puration are  liable  to  ensue.  Paresis  of  the  laryngeal  muscles  is  common, 
due  to  atrophy  of  the  fibres  or  pressure  upon  the  nerve  trunks.     This 


1  -\* 

^■'; 

Fig.  125.— Incipient  Tcbercular  Laryngitis.  Fig.  126.— Tubercular  Laryngitis.    Granu- 

lating tissue  resembling  papillary  tumor. 

may  occur  early  in  the  disease  when  it  is  indicated  only  by  weakness  of 
the  voice  and  loss  of  tonicity  of  the  vocal  cords. 

Etiology. — The  causes  of  this  disease  are  the  same  as  those  of  pul- 
monary tuberculosis,  which  generally  precedes  the  throat  affection. 

Symptomatology. — The  patient  usually  complains  of  first  having 
taken  a  cold,  which  lasted  for  some  time  and  was  followed  by  a  hacking- 
cough,  that  may  have  continued  for  several  months,  or  in  exceptional 
cases  for  two  or  three  years.  As  soon  as  the  disease  has  made  much 
progress,  nutrition  is  disturbed,  and  there  is  gradual  emaciation  with 
fever  and  night  sweats.  The  patient  gradually  loses  strength,  the  voice 
is  weak,  and  later  when  ulceration  takes  place,  and  sometimes  even 
before  this,  deglutition  becomes  difficult,  and  even  phonation  may  be 
painful.  The  pain  on  swallowing  is  liable  to  grow  steadily  worse,  and 
finally  to  become  exceedingly  distressing. 

Indeed,  I  know  of  no  disease  in  which  the  patient  suffers  more  than 
in  the  later  stage  of  laryngeal  tuberculosis,  though  in  the  beginning  he 
may  notice  only  pricking  or  tickling  sensations  in  the  larynx.  "When 
the  disease  is  fairly  established,  the  patient  has  the  appearance  of  one 
with  pulmonary  tuberculosis.  The  skin  is  sallow,  hot,  and  dry  or  bathed 
with  profuse  sweat,  fever  of  three  or  four  degrees  occurs  at  some  part  of 


TUBERCULAR  LARYNGITIS.  437 

the  da}*,  and  the  pulse,  which  is  soft  and  small,  ranges  from  100°  to  120°  F., 
or  higher.  Hoarseness  is  present  in  about  nine-tenths  of  the  cases,  and 
in  some  there  is  complete  aphonia.  Most  cases  soon  exhibit  more  or 
less  dyspnoea,  especially  upon  exertion,  clue  partly  to  weakness  and 
partly  to  obstructed  respiration.  It  is  said  that  laryngeal  obstruction 
occurs  in  about  two  and  two-tenths  per  cent  of  all  cases  of  tuberculosis 
and  becomes  so  grave  as  to  demand  tracheotomy  in  nearly  a  third  of 
these.  Cough  may  not  annoy  the  patient  much,  but  usually  it  is  very 
troublesome.  The  amount  of  expectoration  is  not  very  great  unless  the 
bronchial  tubes  or  pulmonary  parenchyma  are  also  involved,  but  in  the 
latter  part  of  the  disease  the  thick  secretions  which  cover  the  mucous 
membrane  of  the  larynx  are  very  difficult  to  remove  and  cause  the 
patient  much  distress.  The  tongue  is  coated  and  often,  as  in  pulmo- 
nary tuberculosis,  shows  smooth,  red,  oval  patches  from  which  the  epithe- 
lium has  been  entirely  removed.  The  difficulty  in  swallowing,  varying 
much   in  different  patients,  depends  upon  the  extent  and  location  of 


Fig.  127.— Tubercular  Laryngitis.  Fig.  128. — Tubercular  Laryngitis. 

the  ulceration;  in  some  cases  there  may  be  considerable  ulceration  with- 
out difficulty  in  swallowing;  in  others  a  small  ulcer  will  give  great  pain 
and  prevent  taking  of  food. 

"When  the  epiglottis  or  ary-epiglottic  folds  are  so  swollen  that  the 
orifice  of  the  larynx  cannot  be  properly  closed,  fluids  find  their  way  into 
the  trachea  and  excite  spasms  of  cough  attended  by  such  distress  that 
the  patient  prefers  to  suffer  from  thirst  and  hunger  rather  than  to  swal- 
low. Anorexia  is  generally  but  not  always  present.  Upon  examination 
of  the  parts  very  early,  there  is  sometimes  simple  congestion,  but  in  the 
majority  of  cases  the  mucous  membrane  is  anaemic.  Where  congestion 
is  observed  first,  the  progress  of  the  case  is  likely  to  be  slow,  but  cases 
where  anaemia  is  pronounced  generally  advance  rapidly.  The  peculiar 
pyriform  swelling  (Figs.  121,  122,  123)  of  the  ary-epiglottic  folds  is 
present  in  a  large  number  of  cases;  it  may  be  confined  to  one  side  or 
may  be  found  on  both,  and  the  epiglottis  may  or  may  not  be  involved. 
Ulceration  of  the  cords  (Figs.  127,  128)  or  ventricular  bands  (Figs. 
129,  130)  is  common  early  in  the  disease.  The  vocal  cords  act  slug- 
gishly (Fig.  131)  in  many  cases  even  before  swelling  or  ulceration,  and 
their  movements  afterward  are  often  very  much  restricted. 

Diagnosis. — The   affection  is   to   be   distinguished   from   anaemia, 


438 


DISEASES  OF  THE  LARYNX. 


oedema  of  the  larynx,  catarrhal  laryngitis,  and  from  syphilis.  The 
essential  points  in  the  diagnosis  are  the  pain,  the  peculiar  swelling, 
the  character  of  the  ulceration,  and  the  physical  signs  which  may  be 
found  by  examining  the  lungs. 

Tubercular  laryngitis  is  distinguished  from  chronic  catarrhal  laryn- 
gitis by  the  history  and  by  the  physical  appearance.  In  simple  chronic 
laryngitis  there  is  usually  diffused  congestion  with  but  little  swelling. 


Fig.  139.— Tubercular  Laryngitis.  Ulceration 
of  ventricular  bands. 


Fig.  130. — Tubercular  Laryngitis.    Ulceration 
of  ventricular  bands  and  vocal  cords. 


In  the  tubercular  disease,  while  there  may  be  congestion,  more  com- 
monly the  parts  are  anaemic,  and  sooner  or  later  there  is  the  peculiar 
pyriform  swelling  (Figs.  121,  122,  123).  In  the  early  stage  of  laryn- 
geal tuberculosis  when  attended  by  congestion  instead  of  anaemia,  the 
appearance  of  the  parts  may  not  enable  us  to  make  a  diagnosis;  then 
we  must  rely  upon  the  pulmonary  signs  and  the  discovery  of  tuber- 
cle bacilli  in  the  sputum.  Ulceration  is  uncommon  in  catarrhal,  but 
is  the  rule  in  tubercular,  laryngitis;  yet  there  are  rare  cases  of  laryngitis 
with  ulceration,  in  which  it  is  difficult  to  determine  whether  the  pa- 
tient has  tuberculosis  or  not;   and  in  such  instances,  should  we  find  but 


Fig.  131.— Tubercular  Laryngitis.    Paresis  of  muscles  preceding  redema  and  ulceration. 

little  change  in  the  physical  signs  over  the  apex  of  one  lung,  it  will  be 
especially  difficult  to  determine  whether  we  have  an  instance  of  laryn- 
geal tuberculosis  or  one  of  catarrhal  laryngitis.  I  recall  two  or  three 
obstinate  laryngeal  cases  in  which  the  condition  of  the  apex  of  one  lung 
aroused  my  suspicions,  though  I  could  not  be  certain  of  a  deposit,  and 
in  whom  the  ulceration  finally  completely  healed,  and  the  patients 
remained  well  for  a  number  of  years;  apparently  indicating  that  there 
was  no  pulmonary   tuberculosis.     If   ulceration  occur  upon    the  vocal 


TUBERCULAR  LARYNGITIS.  439 

cords  in  front  of  the  vocal  process,  or  upon  the  ventricular  bands,  we 
may  generally  safely  conclude  that  it  is  not  a  case  of  catarrhal  laryngitis; 
and  if  the  ulceration  extends  to  the  upper  part  of  the  larynx  (Fig.  132), 
and  there  is  a  peculiar  pallid  or  light  pink  appearance  of  the  tissues,  with 
more  or  less  swelling,  Ave  are  then  certain  of  our  diagnosis. 

The  disease  can  be  differentiated  from  chronic  catarrhal  laryngitis 
by  the  following  characteristics : 

Laryngeal  tuberculosis.  Chronic  catarrhal  laryngitis. 

Usually  very    slight   congestion.  Congestion  of  membrane.     Usually 

Parts  generally  pale,  change  of  contour  normal  contour  of  parts.     Rarely  ul- 

by  pyriform    swelling   or    ulceration.  ceration.     No  pain,  no  fever. 
Pain,  he,ctic,  rapid  pulse,  sallow  skin. 

Emaciation.  No  emaciation. 

Aphonia  and  dysphagia.  Hoarseness,  but  no  dysphagia. 

Sometimes  anorexia  No  anorexia. 

Short  duration.  Long  duration. 

Usually  tubercles  elsewhere.  No  pulmonary  complication. 

The  essential  points  in  oedema  of  the  larynx  are :  semi-transparency  of 
the  swollen  tissues,  and  the  absence  of  ulceration  and  pain. 

The  distinguishing  features  are  indicated  in  the  following  table : 

Laryngeal  tuberculosis.  (Edema  of  the  larynx. 

May  be  slight  congestion  of  parts.  Usually  no  congestion  of  parts. 

Early  change  of  contour  slight.  Great  change  of  contour  by  marked 

swelling,  with  parts  pale  and  semi- 
transparent. 

Pain,  fever.  Absence  of  pain  and  fever. 

Emaciation.  No  emaciation. 

Respiration  commonly  normal.  Labored  respiration. 

Long  duration.  Short  duration. 

We  may  be  able  to  distinguish  laryngeal  tuberculosis  from  syphilis  of 
the  larynx,  in  the  first  place,  by  the  history,  though  it  is  frequently  difficult 
to  obtain  this  satisfactorily.  The  majority  of  people  who  have  had  syphilis 
flatly  deny  it,  no  matter  how  much  it  affects  the  condition  under  which 
they  are  laboring.  In  syphilis  the  larynx  is  occasionally  involved  early  but 
usually  not  until  the  tertiary  stage;  although  ulceration  may  occur  at 
the  upper  part  of  the  larynx  in  the  secondary  stage.  The  margin  of  a 
syphilitic  ulcer  is  sharply  defined  and  has  an  areola  of  reddened  and 
slightly  thickened  tissue  about  it.  On  the  other  hand,  the  tubercular 
ulcer  has  a  grayish,  worm  eaten  appearance,  the  border  is  not  regular 
and  well  defined,  but  here  and  there  runs  into  the  sound  tissue,  and 
commonly  numerous  small  ulcers  are  visible  about  the  larger  one.  In 
syphilis,  ulceration  is  apt  to  occur  first  upon  the  epiglottis;  in  tuber- 
culosis, on  the  vocal  cords  or  ventricular  bands.  This  is  not  an  absolute 
rule,  but  holds  in  a  large  number  of  cases.     The  ulcer  in  tertiary  syph- 


DISEASES   OF  THE  LARYNJT. 

ilis  is  deep,  and  its  sharply  cut  edge  is  frequently  undermined;  in  tuber- 
culosis the  ulcer  is  shallow  except  in  rare  cases  where  the  process  has 
existed  for  a  long  time,  but  these  have  not  the  sharp  cut,  undermined 
edges  of  the  syphilitic  ulcer.  Very  often  in  the  latter  affection  cica- 
trices may  be  seen  in  the  upper  part  of  the  pharynx  or  about  the  fauces 
and  on  the  soft  palate,  significant  of  former  ulceration.  In  the  syph- 
ilitic affection  the  pain  is  not  nearly  as  marked  as  in  the  tubercular; 
many  cases  of  jn'onounced  syphilitic  ulceration  of  the  throat  occur  in 
which  there  is  no  pain,  and  in  others  it  is  slight:  while  the  tubercular 
ulcer  is  attended  by  severe  pain,  especially  on  attempts  at  deglutition. 
There  are,  unfortunately,  not  a  few  cases  in  which  the  tubercular  infec- 
tion has  occurred  in  syphilitic  subjects  (Fig.  133);  giving  rise  to  an 
atypic  ulceration.  General  evidence  of  tuberculosis  and  marked  laryn- 
geal pain  may  be  associated  with  an  ulcer  of  the  syphilitic  type,  and  in 
such  cases  particularly,  the  results  of  treatment  must  often  clear  up  the 


\ 


Fig.  132.— Tcbercclar  Laryngitis.    Superfi-        Fig.  133.— Ti-bercu-ar   L»Ri>gitis  Occurring 
cial  ulcers  and  fungus  granulations.  in  Patient  with  Specific    History.    Ulceration 

continued  tor  eighteen  months. 

doubtful  points  of  a  diagnosis.  If  upon  the  free  administration  of 
antisyphilitic  remedies  such  as  potassium  or  sodium  iodide  the  ulcera- 
tion begins  to  heal  and  the  patient  to  improve,  we  may  be  at  once  sat- 
isfied of  the  character  of  the  disease.  There  are  some  cases,  however,  in 
which  there  is  undoubted  evidence  of  syphilis,  where  the  patient  will 
not  improve  quickly,  but  only  recovers  after  prolonged  use  of  antisyph- 
ilitic remedies;  therefore,  exceptionally,  a  diagnosis  cannot  be  made  un- 
til the  course  of  the  disease  has  been  watched  for  some  weeks. 

Between  laryngeal  tuberculosis  and  syphilitic  laryngitis  the  following 
are  the  chief  points  of  difference : 

Laryngeal  tuberculosis.  Syphilitic  laryngitis. 

Syphilitic  history. 
Generally  in  adults.  Sometimes  seen  in  children,  if  hered- 

itary. 
Ulceration   usually  superficial,  with  Ulcer  sharp  cut  with  indurated  and 

grayish  worm-eaten  appearance  ;  usu-  congested  border,  sometimes  under- 
ally  steadily  progresses  for  three  or  mined.  May  attain  a  large  size  within 
four  months  to  a  fatal  issue.  two  or  three  weeks,  but  is  apt  to  pro- 

gress but  slowly  afterward  or  may  be 
checked  or  completely  healed. 
Comparatively  short  duration.  Long  duration. 


TUBERCULAR  LARYNGITIS.  441 

Prognosis. — Tubercular  laryngitis  usually  runs  a  rapid  course,  many 
cases  terminating  within  six  months.  It  is  claimed  that  sixty-six  per 
cent  die  within  from  six  to  twenty-four  months.  In  most  instances 
the  earlier  stages  run  on  gradually,  and  it  is  some  time  before  ulceration 
takes  place;  when  this  occurs  and  is  accompanied  by  difficulty  in  swal- 
lowing, we  may  expect  the  disease  to  run  a  rapid  course,  mainly  because 
of  deficient  nutriment.  When  extensive  ulceration  of  the  larynx  is 
found,  we  may  safely  predict  that  the  patient  will  not  live  more  than 
eight  or  twelve  weeks.  A  few  cases  die  within  six  Aveeks  of  the  begin- 
ning of  the  disease.  It  is  not  now  the  belief,  as  formerly,  that  all  of  these 
cases  are  fatal,  for  there  is  ample  proof  that  a  few  recover.  We  nearly  al- 
ways find  accompanying  pulmonary  tuberculosis;  and  it  is  probably  safe 
to  say  that  where  laryngeal  tuberculosis  is  so  complicated,  nine-tenths 
of  the  patients  die.  Finally,  while  the  local  reparative  process  depends 
largely  upon  the  ability  to  better  the  general  nutrition,  the  hope  of  cure, 
as  well  suggested  by  Jarvis,  should  be  also  based  upon  the  extent  of 
ulceration  (Transactions  American  Laryngological  Association,  1883). 

Treatment. — Constitutional  treatment  is  of  the  first  importance, 
and  should  be  similar  to  that  for  pulmonary  tuberculosis.  Local  sooth- 
ing applications,  in  the  form  of  inhalations,  sprays,-  and  powders  are 
of  more  or  less  benefit.  The  principal  inhalations  which  are  recom- 
mended are :  the  compound  tincture  of  benzoin,  camphorated  tincture  of 
opium,  or  solutions  of  opium  or  belladonna  with  or  without  carbolic 
acid,  or  eucalyptol  (Forms.  56  to  59).  These  give  some  relief,  but  are  not 
of  great  importance,  for  they  do  not  appear  to  check  the  disease.  Sooth- 
ing sprays  which  may  be  applied  cold  by  the  atomizer  are  preferable 
when  the  patient  is  able  to  be  out  of  doors,  as  the  warm  inhalations  pre- 
dispose to  acute  colds.  Early,  before  much  swelling  has  taken  place, 
mild  astringents  such  as  carbolic  acid  gr.  ij.,  and  zinc  sulphate  gr.  ij., 
ad  3  i.,  or  similar  preparations  are  often  helpful.  These  should  be  ap- 
plied by  the  physician  every  second  day  when  convenient,  in  sufficient 
strength  to  cause  smarting  for  about  half  an  hour,  or  by  the  patient 
twice  daily  of  a  strength  that  will  cause  some  discomfort  for  only  five  or 
ten  minutes.  Menthol  has  also  been  highly  recommended  as  a  spray  or 
inhalation  in  the  strength  of  a  drachm  to  the  ounce  of  liquid  albolene. 

Wm.  T.  Belfield  has  recently  communicated  to  the  New  York  Medi- 
cal Record  a  preliminary  paper  on  the  use  of  iodine  trichloride  in  sur- 
gery; from  which  I  am  led  to  hope  for  good  effects  in  the  local  treat- 
ment of  tubercular  laryngitis;  and  also  in  the  general  treatment  of 
pulmonary  phthisis. 

The  demonstrations  by  W.  S.  Haines,  revealed  to  him  that  when 
brought  in  contact  with  saliva,  blood,  pus,  and  other  animal  matter,  iodine 
trichloride  is  quickly  decomposed;  setting  free  iodine  and  chlorine  in 
the  nascent  state,  most  potent  for  destruction  of  disease  germs.  I  have 
used  this  remedy   in   many   cases  of   laryngeal    tuberculosis    applied 


44">  DISEASES  OF  THE  LARYNX 

by  spray  in  a  solution  in  distilled  water  gr.  ss.  to  gr.  iiss.  ad  f  i., 
and  have  used  it  hypodermically  in  the  manner  recommended  when 
speaking  of  pulmonary  tuberculosis  for  Shurly's  solution  of  iodine.  Hy- 
podermically it  may  be  used  in  solution  in  distilled  water;  gr.  i.  to  gr. 
iiss.  ad   3   i.  aud  iT|  x.  to  TT[  xx.  may  be  administered. 

The  results  have  been  favorable,  and  justify  its  extended  trial  in  all 
forms  of  tuberculosis  of  the  air  passages  and  pleura. 

Powders  are  often  better  than  sprays,  because  patients  generally  apply 
them  to  the  throat  more  easily.  The  most  serviceable  powders  are:  iodo- 
form, morphine,  bismuth,  tannin,  iodol,  and  gum  benzoin,  in  various  com- 
binations with  each  other  and  sugar  of  milk,  starch  or  acacia  (Form. 
163-165,  172,  177);  an  excellent  soothing  powder  is  composed  of  equal 
parts  of  gum  benzoin  and  bismuth,  with  two  parts  of  iodoform.  The 
latter,  however,  is  so  exceedingly  unpleasant  to  many  patients  that  it  is 
better  to  substitute  iodol,  which  has  nearly,  if  not  quite,  as  good 
effect  and  has  but  slight  odor.  When  there  is  much  pain,  unless  con- 
tra-indicated by  idiosyncrasy,  morphine  may  be  advantageously  combined 
with  any  of  these  powders  in  the  proportion  of  about  five  per  cent,  so 
that  the  patient  will  receive  one-tenth  of  a  grain  with  each  insufflation. 
For  the  same  purpose  cocaine  has  been  highly  recommended,  but  I  have 
found  that  it  affords  the  patient  very  little  relief  and  often  proves  to  be 
exceedingly  uncomfortable.  Morphine,  iodol,  and  bismuth,  in  proper 
proportions  (Form.  165),  give  more  relief  than  other  combinations,  in 
my  experience;  though  a  small  amount  of  tannin  or  gum  benzoin  may 
be  advantageously  added,  if  not  too  irritating.  If  the  epiglottis  be- 
comes destroyed  by  ulceration,  the  patient  may  need  to  be  fed  with 
an  oesophageal  tube,  which  if  of  small  size  may  be  passed  with- 
out much  discomfort.  The  patients  sometimes  swallow  more  easily 
with  the  head  low  in  the  manner  recommended  for  patients  who  are 
wearing  the  laryngeal  tube.  They  often  suffer  greatly  from  thirst  and 
hunger,  rather  than  endure  the  agony  caused  by  swallowing.  For  miti- 
gating the  torture  under  these  circumstances,  I  have  had  great  satisfac- 
tion from  the  use,  by  swab  or  atomizer,  of  a  pigment  of  morphine,  carbolic 
acid,  and  tannic  acid  with  glycerin  and  water  (Form.  139).  This  applied 
to  the  larynx  in  full  strength  usually  causes  intense  smarting  for  a 
few  moments  and  subsequently  so  benumbs  the  parts  that  the  patient 
may  swallow  readily,  the  anaesthesia  continuing  for  some  hours.  In  one 
case  where  I  frequently  used  it,  anaesthesia  would  often  continue  for 
thirty-six  hours.  I  often  give  this  preparation  diluted  with  an  equal 
quantity  of  water,  for  the  patient  to  use  by  the  atomizer  two  or  three 
times  daily.  There  is  now  and  then  a  case,  in  which  it  only  causes 
suffering.  F.  D.  Owsley,  of  Chicago,  informs  me  that  he  has  been  able 
to  give  great  relief  in  these  cases  by  having  the  patient  spray  into  the 
larynx,  before  eating,  a  saturated  solution  of  oil  of  cloves  (f  of  one  per  cent) 
in  water.  Tracheotomy  has  been  recommended  in  these  cases,  not 
only  to  prevent  dyspnoea,  but  also  to  give  the  larynx  rest.     With  the 


SYPHILITIC  LARYNGITIS.  443 

latter  end  in  view,  it  lias  been  advised  comparatively  early  in  tubercu- 
lar laryngitis,  but  there  is  no  proof  that  it  improves  the  patient's 
chances  for  recovery,  and  I  think  it  unjustifiable,  excepting,  of  course, 
when  there  is  marked  obstruction  of  the  glottis,  in  which  case  it  may  be 
the  means  of  prolonging  life  for  several  months. 

The  question  of  artificial  feeding  in  these  cases  is  ably  discussed  in  a  paper 
by  Beverley  Robinson,  to  be  found  in  the  Transactions  of  the  American  Laryngo- 
logical  Association,  1883. 

SYPHILITIC   LARYNGITIS. 

The  local  laryngeal  phenomena  of  syphilis  vary  at  different  stages 
of  the  disease.  Syphilitic  laryngitis,  although  frequent,  is  present  in 
only  a  comparatively  small  portion  of  cases  of  all  varieties  of  throat 
disease.  Primary  syphilitic  laryngitis  is  extremely  rare.  The  symp- 
toms of  secondary  syphilitic  laryngitis  make  their  appearance  with- 
in from  six  to  twenty-four  months  after  infection,  and  are  charac- 
terized by  hypersemia  with  alteration  of  the  voice  and  frequently  condy- 
lomatous  formations.  The  tertiary  manifestations  do  not  usually  appear 
until  three  or  four  years  or  much  longer  after  the  primary  affection, 
and  it  is  not  uncommon  to  observe  cases  in  which  they  are  delayed  fif- 
teen or  twenty  years.  This  stage  is  indicated  by  gummatous  tumors,  deep 
ulcerations,  and  vicious  cicatrices,  with  consequent  dyspnoea  and  altera- 
tion of  the  voice.  Syphilitic  patients  are  more  subject  than  others  to 
acute  inflammations  of  the  larynx,  which  are  usually  slow  to  recover. 
The  disease  is  more  frequent  in  men  than  in  women,  and  the  tertiary 
symptoms  are  about  twice  as  frequent  as  the  secondary.  In  secondary 
syphilis  of  the  larynx,  chronic  hyperaemia  and  superficial  ulcers  are 
found,  but  Mackenzie  thinks  that  smooth,  yellow,  round  or  oval  condy- 
lomata are  most  characteristic  (Diseases  of  the  Throat  and  Nose,  Vol. 
I,  j).  355).  These  are  from  five  to  ten  millimetres  in  diameter,  but  may 
be  twice  as  large,  and  are  most  frequently  found  upon  the  epiglottis  or 
posterior  commissure. 

Lennox  Browne  states  that  he  has  seen  several  cases  in  which  these 
formations  were  essentially  like  warty  growths  (Diseases  of  the  Throat, 
second  edition).  There  is  usually  nothing  characteristic  about  the 
persistent  hyperaamia,  but,  as  Browne  observes,  in  many  cases  there 
is  a  well  defined,  mottled  discoloration,  apparently  less  superficial,  and 
not  so  vivid  in  color  as  in  simple  chronic  inflammation.  This  is  most 
distinct  on  the  vocal  cords.  Small  superficial  ulcers  or  mucous  patches 
are  occasionally  seen  on  the  ventricular  bands,  edge  of  the  epiglottis  or 
posterior  part  of  the  larynx.  These  are  described  by  Gottstein  as  round 
or  elongated,  grayish  white  spots  of  thickened  epithelium,  slightly 
raised  above  the  congested  tissue  which  surrounds  them,  and  either 
gradually  shading  off  into  it  or  sharply  defined.  In  tertiary  syphilis  of 
the  larynx,  gummata,  deep  ulceration,  cicatrices,  or  chronic  thickening 
(Fig.  137)  are  characteristic.     The   gummata   may  occur   singly  or   in 


444 


DISEASES   "F  THE  LARYNX. 


groups,  and  are  most  frequent  upon  the  posterior  commissure  or  aryt- 
enoid cartilages.  They  are  usually  observed  as  round,  smooth  eleva- 
tions of  the  same  color  as  the  surrounding  tissue,  or  of  a  slightly  yellow- 
ish tint;  but  as  breaking  down  occurs  they  usually  become  yellowish  at 
the  centre.  The  ulceration  may  he  superficial  at  first,  but  ere  long  it 
becomes  deep  and  destructive.  It  may  occur  in  any  portion  of  the 
larynx,  but   the  epiglottis  is  the  most  vulnerable  point,  and  frequently 


Fig.  VjA. — Condyloma  on  the  Upper  Surface 
of  the  Epiglottis  (Mackenzie;. 


Fig.  135. — Gumma  i  Mackenzie). 


it  is  destroyed  by  the  progress  of  the  disease.  When  the  ulcers 
heal,  resulting  cicatrices  may  seriously  interfere  with  swallowing  or 
respiration.  These  ulcers  are  often,  though  not  always,  the  result  of 
softening  of  tin-  gummatous  tumors.  Chronic  thickening  of  the  walls 
of  the  larynx  or  of  the  vocal  cords,  with  anchylosis  of  the  cartilaginous 
articulations,  are  among  the  common  results  of  the  disease. 

Etiology. — The  affection  is  due  to  constitutional  syphilis,  either  in- 
herited or  acquired.  It  sometimes  gradually  extends  from  the  pharynx, 
but  more  frequentlv  occurs  after  it  has  disappeared  from  that  locality. 

Symptomatology. — By  careful  inquiry,  a  history  of  some  of  the 
manifestations  of  hereditary  or  acquired  syphilis  may  generally  be  ob- 


Fig.  136.— Multiple  Gummata  <Mandl). 


Fig.  137. -Syphilitic  Laryngitis. 


tained,  though  the  great  majority  of  patients,  if  the  question  is  asked 
them  directly,  will  positively  deny  ever  having  been  affected.  The 
symptoms  will  necessarily  vary  greatly  in  proportion  to  the  amount  of 
tissue  involved  and  the  parts  immediately  affected.  There  may  be  only 
the  symptoms  of  a  slight  laryngitis,  or,  in  the  advanced  disease,  diffi- 
culty in  swallowing,  aphonia,  or  dangerous  dyspnoea.  Superficial  ulcers 
usually  occur  in  from  six  to  twelve  months  after  primary  infection. 
The  condylomata  are  seldom  troublesome  excepting  as  regards  the 
voice,  and  they  often  spontaneously  disappear.     The  symptoms  of  the  sec- 


SYPHILITIC  LARYNGITIS.  445 

ondary  disease,  as  in  other  parts,  rapidly  decline  under  appropriate  treat- 
ment, but  show  a  peculiar  tendency  to  recurrence.  The  tertiary  symptoms 
may  not  occur  until  many  years  after  inoculation;  Mackenzie  states 
that  in  hereditary  cases  he  has  never  seen  the  disease  before  the  seventh 
year  of  age.  In  these  unfortunate  cases  I  have  seldom  seen  the  disease 
develop  before  the  person  was  fifteen  years  of  age;  though  several  in- 
stances have  been  reported  of  its  occurrence  in  young  infants.  Even 
when  there  is  extensive  ulceration,  patients  are  peculiarly  exempt  from 
pain  except  on  deglutition  and  occasionally  on  using  the  voice,  and  even 
then  it  may  be  absent  if  the  perichondrium  is  not  involved. 

Fever  is  often  present  in  severe  cases,  and  colliquative  sweating  may 
occur  in  those  who  are  much  debilitated.  Specific  eruptions  upon  the  skin 
are  said  to  be  infrequent  in  these  patients.  The  voice  is  easily  affected 
by  exposure  or  vocal  exertion,  and  the  singing  voice  is  commonly  de- 
stroyed. Hoarseness  is  usual  early  in  the  disease,  and  in  many  cases 
there  is  a  peculiar  huskiness  of  the  tone  said  to  be  quite  characteristic. 
Impairment  of  the  voice  may  gradually  progress  until  there  is  complete 
aphonia;  if,  however,  the  disease  is  limited  to  the  epiglottis,  the  voice 
may  be  but  little  influenced,  and  even  after  complete  destruction  of 
this  portion  of  the  larynx  the  voice  is  sometimes  quite  restored.  Respi- 
ration is  seldom  affected  in  the  secondary  disease;  but  in  the  tertiary, 
marked  and  even  dangerous  dyspnoea  may  result  from  thickening  of  the 
.  parts ;  or  from  new  growths,  anchylosis  of  the  cartilages,  or  contraction 
of  cicatricial  tissues.  The  dyspnoea  may  only  be  noticed  on  exertion 
or  on  the  occurrence  of  acute  inflammation,  but  usually  it  gradually 
increases,  with  frequent  exacerbations  until  eventually  life  is  threat- 
ened by  exhaustion,  by  spasm  of  the  glottis,  or  by  suffocative  attacks  due 
to  collection  of  tenacious  secretions  upon  the  parts.  Cough  is  often 
present,  but  it  is  not  usually  a  prominent  symptom  in  either  secondary 
or  tertiary  forms  of  the  disease.  Early  it  is  occasioned  simply  by  efforts 
to  remove  the  secretions,  and  is  not  peculiar;  but  when  the  larynx  be- 
comes constricted  the  cough  often  acquires  the  characteristic  stridor  and 
spasm  of  true  croup,  and  when  the  trachea  is  obstructed  it  may  closely 
resemble  the  cough  of  pertussis.  Constitutional  symptoms  are  usually 
slight  unless  the  disease  in  the  larynx  seriously  interferes  with  degluti- 
tion or  respiration.  The  appetite  remains  good  and  digestion  normal  in 
the  majority  of  cases,  but  obstinate  dyspepsia  may  be  caused  by  accom- 
panying syphilitic  disease  of  the  stomach.  In  the  early  stages  there  is 
seldom  difficulty  in  swallowing,  but  in  the  tertiary  form  dysphagia  is 
often  present,  especially  where  the  pharyngeal  border  of  the  posterior 
wall  of  the  larynx  is  ulcerated.  Thickening  of  the  epiglottis  does  not 
seem  to  interfere  greatly  with  the  act  of  swallowing,  and  sometimes 
ulceration  or  even  extensive  destruction  of  this  valve  (Fig.  138)  has  little 
effect  upon  deglutition.  Upon  laryngoscopic  examination,  congestion 
or  other  changes  already  mentioned  are  discovered.       The  superficial 


44i; 


DISEASES  OF  THE  LARYN.Y. 


ulceration  of  the  secondary  stage  most  frequently  occurs  upon  the  ven- 
tricular bands,  the  epiglottis,  or  posterior  walls  of  the  larynx.  Condylo- 
mata, if  found,  are  usually  at  the  posterior  commissure,  or  on  the  epi- 
glottis. In  the  tertiary  affection  the  general  surface  of  the  larynx  is  usu- 
ally of  a  deep  pink  or  light  red  color.  Gummata  have  the  appearance 
already  described.  The  superficial  ulcer  of  this  stage  has  sharply 
defined  borders,  which  distinguish  it  from  tubercular  ulceration.  The 
deep  ulcer  has  been  well  described  by  Turck,  as  more  or  less  circular  in 


<*:<$*■  ■ 


Fig.  138. — Syphilitic  Laryngitis.    Partial  destruction  of  epiglottis. 


form,  with  sharp  margins  sometimes  elevated  and  surrounded  by  an  in- 
flammatory areola.  The  floor  is  covered  by  a  dirty  yellowish  white 
coating.  When  the  ulcers  heal,  the  resulting  cicatrices  are  dense,  fibrous, 
and  unyielding,  and  exceedingly  prone  to  return  if  divided.  There  is 
usually  no  external  swelling  of  the  larynx,  excepting  when  there  is  ex- 
tensive perichondritis,  but  enlargement  of  the  cervical  glands  is  common. 
Diagnosis. — The  disease  is  to  be  distinguished  from  simple  chronic 
catarrhal  inflammation  from  tubercular  laryngitis,  and  from  benign  and 
malignant  tumors.     The  essential  points  in  the  diagnosis  are :  the  history 


Fig.  139.— Syphilitic  Ulceration  of  Epiglot- 
tis. Hypertrophy  of  left  ventricular  band  and 
ary-epiglottic  fold  (Mackenzie). 


Fig.  140.— Syphilitic  Ulceration  (Turck). 
a.  b,  c.  Remnants  of  epiglottis. 


and  absence  of  grave  constitutional  symptoms,  the  presence  of  scars  in 
the  pharynx  or  upon  other  parts  of  the  body  and  of  one  or  more  deep 
ulcers  of  the  larynx.  After  the  surgeon  has  satisfied  himself  of  the 
nature  of  the  disease  by  the  appearance  of  the  parts  and  a  cautious  in- 
quiry about  former  symptoms,  such  as  prolonged  sore  throat,  loss  of  hair, 
and  eruptions  upon  the  body,  he  should  ask  the  patient,  How  long  since 
you  had  syphilis  ?  Put  in  this  way  the  question  is  nearly  always  an- 
swered honestly.  While  there  is  simply  hypera?mia  without  ulceration 
it  is  impossible  to  arrive  at  an  accurate  diagnosis  from  the  examination 


SYPHILITIC  LARYNGITIS.  U7 

of  the  parts  alone,  but  the  discovery  of  mucous  patches  or  tertiary 
ulcers,  together  with  the  appearance  of  the  pharynx  and  of  the  fauces, 
and  the  patient's  history,  with  the  absence  in  most  cases  of  constitu- 
tional symptoms,  will  nearly  always  enable  us  to  make  an  accurate  diag- 
nosis. Sometimes,  however,  we  are  obliged  to  give  antisyphilitic  treat- 
ment for  some  time  before  we  can  be  certain  of  the  case. 

Between  typical  cases  of  tubercular  laryngitis  and  syphilitic  laryngitis 
there  is  little  difficulty  in  making  a  diagnosis;  but  when  the  two  diseases 
are  combined,  or  when  the  j>atient  is  greatly  debilitated,  it  is  sometimes 
impossible  to  arrive  at  an  accurate  conclusion.  Usually  there  is  no  fever, 
no  excitation  of  the  pulse,  and  no  emaciation  in  the  syphilitic  affection, 
while  all  of  these  are  present  in  the  tubercular  disease.  In  the  early 
stages  of  both  there  may  be  simple  hyperemia  of  the  parts,  but  very 
soon  there  is  a  peculiar,  pale  red  swelling  in  tuberculosis,  having  a  semi- 
solid appearance  much  like  oedema,  instead  of  the  darker  red  color  and 
dense  appearance  of  syphilitic  swelling.  The  ulcers  in  tuberculosis  are  usu- 
ally comparatively  numerous;  they  are  superficial  with  irregular,  poorly 
defined  borders ;  and  are  attended  by  much  pain.  This  is  not  the  case  in 
syphilis.  The  ulceration  is  usually  rapid  in  syphilitic  laryngitis,  slow  in 
tubercular.  It  is  more  apt  to  begin  at  the  upper  }3art  of  the  larynx  in  the 
former,  and  at  the  lower  in  the  latter.  In  syphilitic  laryngitis,  adminis- 
tration of  the  iodides  usually  causes  speedy  improvement,  whereas  in  tu- 
berculosis it  is  likely  to  work  an  injury  to  the  patient,  and  the  symptoms 
grow  worse.  Tubercular  laryngitis  is  nearly  always  attended  by  distinct 
signs  of  pulmonary  phthisis. 

The  rapid  growth  of  condylomata,  their  location,  and,  under  appro- 
priate treatment,  their  speedy  disappearance,  together  with  other  evi- 
dences of  specific  disease,  will  usually  enable  us  to  easily  distinguish 
them  from  papillomata  or  other  laryngeal  tumors.  The  gummata  are 
not  likely  to  be  mistaken  for  any  other  growths  in  the  larynx.  The 
fungous  growths  which  sometimes  occur  about  the  edges  of  syphilitic 
ulcers  are  not  likely  to  be  mistaken  for  any  of  the  benign  tumors  of  the 
larynx,  but  are  not  unlike  those  which  may  be  observed  in  some  cases 
of  tuberculosis,  and  can  only  be  distinguished  from  the  latter  by  a  care- 
ful consideration  of  other  symptoms  and  signs. 

In  the  early  stages,  while  there  is  simple  congestion  of  the  larynx,  it 
may  be  impossible  to  distinguish  cancer  from  syphilitic  laryngitis,  but 
congestion  in  the  malignant  disease  is  usually  confined  to  one  side  or  to 
a  limited  portion  of  the  larynx,  whereas  that  of  the  specific  affection  is 
more  apt  to  be  uniformly  distributed.  In  cancer  the  growth  precedes 
the  ulceration,  whereas  in  syphilis  the  ulceration  is  often  first.  In 
syphilis  the  ulceration  is  more  rapid,  though  there  is  less  inflammation 
about  it,  and  the  ulcers  are  usually  smaller  and  more  apt  to  be  multiple. 
In  the  later  stages  of  cancer,  when  a  large,  irregular  tumor  has  been 
formed  there  can  be  but  little  difficulty  in  making  the  diagnosis.     In 


448  DISEASES  OF  THE  LARYNX. 

rare  cases  where  there  has  been  much  thickening  of  the  larynx,  with 
ulceration  and  cicatrization  so  that  portions  of  the  organ  are  much  dis- 
torted, it  is  sometimes  impossible  at  first  to  tell  with  which  disease  we 
are  dealing.  In  these  cases,  as  suggested  by  Lennox  Browne,  much 
reliance  may  be  placed  upon  the  evidence  obtained  by  frequently  weigh- 
ing the  patient  while  he  is  taking  the  iodides.  Although  under  antisyph- 
iiitic  treatment,  persons  suffering  from  cancer  of  the  larynx  sometimes 
do  well  for  a  short  time;  improvement  soon  ceases,  and  they  lose  weight; 
whereas  in  the  syphilitic  disease  there  is  generally  steady  increase  in 
weight  for  a  considerable  time  while  this  treatment  is  pursued. 

Prognosis. — In  the  secondary  stage  of  the  disease  'appropriate  treat- 
ment usually  effects  a  speedy  cure,  though  the  singing  voice  may  be 
permanently  lost.  However,  there  is  a  peculiar  predisposition  to  re- 
lapses under  exposure  to  the  causes  of  catarrhal  inflammation.  In  the 
tertian*  variety  a  favorable  prognosis  may  be  given  where  the  case  comes 
under  observation  sufficiently  early;  but  if  the  perichondrium  or  the 
cartilages  are  extensively  involved,  there  is  great  danger  to  life.  In  either 
case  restoration  to  the  larynx  of  its  perfect  functions  is  impossible, 
though  improvement  may  be  expected  under  appropriate  treatment. 
The  ulcerations  will  usually  heal  within  two  or  three  weeks,  but  the 
thickening  or  cicatrices  remaining  may  interfere  with  deglutition,  res- 
piration, or  phonation.  Death  may  result  from  acute  oedema,  and 
has  occurred  from  hemorrhage  though  this  is  not  a  likely  termina- 
tion. Chronic  thickening  or  distortion  of  the  larynx  is  liable  to  remain 
permanent  in  all  cases  where  there  has  been  extensile  ulceration:  and 
gradual  exhaustion  due  to  stenosis  of  the  larynx  may  finally  wear  the 
patient  out  if  tracheotomy  is  not  performed.  Destruction  of  the  epi- 
glottis may  for  a  short  time  interfere  with  deglutition,  but  the  patient 
soon  learns  to  swallow  without  this  valve. 

Tkeatmext. — In  the  secondary  disease,  local  stimulating  applica- 
tions, similar  to  those  recommended  for  simple  chronic  laryngitis,  are 
indicated  and  are  peculiarly  beneficial.  For  this  purpose  solutions  of 
zinc  chloride  or  copper  sulphate  have  been  found  most  useful.  A 
mild  mercurial  course  is  also  indicated;  and  whenever  condylomata  or 
ulcerations  appear,  potassium  or  sodium  iodide  should  be  given.  Bitter 
and  ferruginous  tonics  are  indicated  if  the  appetite  is  fitful.  The  use 
of  tobacco  in  any  form  should  be  interdicted,  and  alcoholic  stimulants 
are  generally  hurtful.  In  the  tertiary  form  of  the  disease  the  greatest 
reliance  is  placed  upon  the  internal  administration  of  potassium  or 
sodium  iodide.  If  for  any  reason  these  cannot  be  borne,  the  patient  may 
be  given  a  mercurial  course;  gold  and  sodium  chloride  sometimes  acts 
equally  well.  It  is  sometimes  found  necessary  to  use  the  iodides  in 
very  large  doses;  for  example,  I  have  seen  a  patient  in  whom  twenty 
grains  of  potassium  iodide  taken  four  times  daily  had  no  effect ;  whereas, 
when  he  was  siven  much  larger  doses  the  condition  of  the  larynx  im- 


SYPHILITIC  LARYNGITIS  IN  INFANTS.  449 

mediately  improved.  The  remedy  should  always  be  given  freely  diluted 
with  water,  and  it  is  best  to  begin  with  small  doses,  which  can  be  steadily 
increased.  I  usually  begin  with  seven  and  one-half  grains  after  each 
meal  and  at  bedtime,  and  the  dose  is  increased  each  day  two  and 
a  half  grains  until  fifteen  or  twenty  grains  are  taken  at  a  close.  If 
with  this  treatment  the  patient  does  not  improve,  and  the  symptoms  of 
iodidism  do  not  occur,  the  dose  is  increased  each  clay  five  grains  until 
thirty,  forty,  or  sixty  grains,  and  in  extreme  cases  even  one  hundred 
and  twenty  grains  are  taken  at  a  dose  four  times  daily.  The  maxi- 
mum dose  having  been  reached,  it  is  continued  for  two  or  three  days, 
and  then  the  patient  again  begins  with  the  minimum  dose  and  increases 
the  quantity  daily  as  in  the  first  instance.  This  plan  has  seemed  to 
me  much  more  satisfactory  than  the  continued  administration  of  large 
doses.  Usually  it  is  well  to  direct  the  patient  to  drink  nearly  half  a 
pint  of  water  with  each  dose  of  the  medicine.  Locally,  Lennox  Browne 
(Diseases  of  the  Throat,  third  edition),  especially  recommends  the  solid 
silver  nitrate,  or,  when  the  epiglottis  is  ulcerated,  the  galvano-cautery. 
I  prefer  at  first  the  tincture  of  iodine  full  strength,  thoroughly  and 
accurately  applied  to  ths  ulcers  daily  for  five  or  six  days,  and  subse- 
quently less  often  until  healing  has  occurred.  In  case  the  tincture  of 
iodine  fails,  I  resort  to  co]3per  sulphate  in  solution  of  from  gr.  x.  to 
xx.  ad  5  i.,  or  to  zinc  chloride  in  solutions  of  from  gr.  xv.  to  xxx.  ad  \  i. 
Under  this  course,  even  large  ulcers  will  usually  heal  within  two  or 
three  weeks.  After  cicatrization  of  the  ulcers  has  taken  place,  if  sten- 
osis of  the  larynx  occurs,  it  must  be  dilated  by  means  of  Schrotter's 
bougies  or  O'Dwyer's  laryngeal  tubes,  as  described  in  the  treating  of  sten- 
osis of  the  larynx.  At  times  the  specific  medication  should  be  discon- 
tinued and  tonics  substituted.  Where  the  patient  is  much  run  down,  it 
is  best  to  administer  nux  vomica  and  quinine  while  the  specific  course  is 
continued. 

SYPHILITIC    LARYNGITIS    IN"    INFANTS. 

The  attention  of  the  profession  was  first  directed  to  congenital  syph- 
ilis of  the  larynx  by  John  N.  Mackenzie,  of  Baltimore,  according  to 
whom  it  is  not  very  infrequent,  and  occurs  mostly  within  the  first  year 
of  life  {American  Journal  of  Medical  Sciences,  1880).  It  is  character- 
ized by  cough,  dysphonia,  dysphagia,  dyspnoea,  and  deep,  destructive 
ulceration.  The  voice  of  the  child  may  pass  through  all  stages  from 
slight  huskiness  to  aphonia.  Paroxysmal  cough  is  frequent,  and  res- 
piration is  more  or  less  embarrassed  according  to  the  condition  of  the 
part.  Laryngismus  stridulus  is  also  spoken  of  by  John  N.  Mackenzie 
as  a  not  infrequent  symptom  in  these  cases.  Deglutition  is  often  diffi- 
cult, and  cutaneous  eruptions  may  be  present. 

Diagnosis. — The  diagnosis  must  be  made  from  the  symptoms,  and 
personal  and  hereditary  history  ;  from  the  signs  as  manifested  upon 
29 


450  DISEASES   OF  THE  LARYNX. 

the  skin  or  the  fauces;  and  from  the  appearance  of  the  larynx,  when 
laryngoscopic  inspection  is  possible. 

Prognosis. — The  prognosis  is  always  unfavorable.  The  younger 
the  child,  the  more  rapid  will  be  the  course  and  the  greater  the  certainty 
of  a  fatal  termination.  Some  cases  recover  under  proper  treatment, 
but  there  is  a  strong  predisposition  to  recurrence. 

Treatment. — The  treatment  is  essentially  the  same  as  for  the  ac- 
quired disease;  but  when  difficulty  in  respiration  occurs,  prompt  intuba- 
tion or  tracheotomy  should  be  performed.  The  former  is  to  be  espe- 
cially recommended,  as  it  will  generally  insure  sufficient  breathing  space 
and  give  time  for  the  administration  of  medicine  adapted  to  promote 
healing  of  the  parts.  If  stenosis  of  the  larynx  occurs,  so  that  it  is  nec- 
essary to  wear  an  instrument  permanently,  tracheotomy  is  preferable; 
but  the  good  results  obtained  from  intubation  in  chronic  stenosis  of 
the  larynx  would  lead  me  to  recommend  first  a  persistent  trial  of 
O'Dwyers  method. 


CHAPTER   XXVI. 

DISEASES   OF   THE   LAKYNX.— Continued. 

LUPUS   OF  THE  LARYNX. 

Lupus  of  the  larynx  is  a  rare  affection  said  to  occur  with  about  eight 
per  cent  of  all  cases  of  lupus  in  other  parts  of  the  body.  It  is  usually 
secondary  to  lupus  of  the  face,  is  more  frequent  in  women  than  in 
men,  and  is  most  common  in  the  lower  classes  of  society. 

For  a  history  of  this  disease  we  are  indebted  largely  to  G.  M. 
Lefferts,  of  New  York  {American  Journal  of  the  Medical  Sciences,  April, 
1878).  The  literature  has  been  much  enriched  by  Chiari  and  Eiehl 
(Lupus  vulgaris  Laryngis,  Vierteljaliresschrift  fur  Derm,  und  Syph., 
1882) ;  Morris  Asch,  of  New  York ;  F.  I.  Knight,  of  Boston  (Archives  of 

Fig.  141.— Lupus  of  Larynx  (Ziemssen).       Fig.  142.— Lupus  of  Larynx  (Turck).    a.  b.  Epiglottis. 

Laryngology,  1881),  and  by  numerous  other  writers.  Although  the  vari- 
ous investigators  have  observed  numerous  cases,  it  is  not  yet  possible 
to  point  out  any  diagnostic  characteristics  of  the  disease.  ■ 

Axatomical  autd  Pathological  Characteristics. — According  to 
Lefferts,  the  essential  pathological  characteristic  is  hypertrophy  of  tissue. 
This  is  followed  by  slow  but  very  destructive  ulceration,  and  when  heal- 
ing occurs  the  cicatricial  tissue  is  very 'hard  and  of  low  vitality.  About 
these  scars  congested  nodules  are  usually  seen. 

Etiology. — The  causes  of  the  disease  are  not  known.  It  has  gener- 
ally been  considered  as  an  evidence  of  a  scrofulous  taint.  By  some  it  is 
believed  to  be  tubercular.  The  experiments  of  Koch,  in  discovering 
tubercle  bacilli  in  the  lupus  nodules,  and  from  them  obtaining  pure  cul- 
tures, while  not  furnishing  conclusive  evidence  of  the  tubercular  charac- 


452  DISEASES  OF  THE  LARYNX. 

ter  of  the  disease,  make  this  the  most  plausible  hypothesis,  though  the 
difference  in  the  clinical  aspect  of  the  two  affections  has  not  as  yet 
been  satisfactorily  explained.  Whatever  the  ultimate  cause  of  the  dis- 
ease, it  is  evidently  the  same  as  that  which  causes  lupus  on  other  por- 
tions of  the  body.  According  to  Harries  and  Campbell,  the  disease 
requires  for  its  development  a  suitable  soil  ("  Lupus,"  etc.,  London,  1886) 
— possibly  allied  to  tuberculosis  and  scrofula;  a  predisposing  cause, 
particularly  traumatism;  and  an  exciting  cause,  probably  a  micro- 
organism. 

Symptomatology. — At  first  the  patient  may  complain  of  mild  sore 
throat,  but  the  symptoms  are  not  marked  and  are  entirely  out  of  propor- 
tion to  the  physical  signs.  There  is  often  neither  pain  nor  discomfort, 
and  the  patient  is  usually  ignorant  of  laryngeal  disturbance;  but  as  the 
disease  progresses,  the  voice  is  often  affected  and  in  many  cases  dyspnoea 
is  developed.  In  some  there  is  distressing  cough  and  a  sense  of  obstruc- 
tion in  the  throat,  and  occasionally  there  is  complaint  of  dysphagia. 
No  characteristic  physical  appearances  are  observed  upon  laryngoscopy 
examination,  but  in  many  cases  congested  nodules  will  be  seen  on  the 
epiglottis  or  anterior  surface  of  the  arytenoids.  These  nodules  are 
irregular  or  may  be  almost  spherical.  Ulcers  or  cicatrices  may  also  be 
seen,  similar  to  those  observed  when  the  disease  affects  the  face.  Ramon 
de  la  Sota  speaks  of  marked  absence  of  bleeding  from  the  ulcers  (Trans- 
actions of  the  American  Laryngological  Association,  1886). 

Diagnosis. — The  disease  is  to  be  distinguished  from  tuberculosis, 
syphilis,  or  cancer  of  the  larynx.  The  most  important  points  in  the 
differentiation  are  the  history  and  the  presence  of  lupus  externally. 
When  the  latter  exists  the  diagnosis  is  not  usually  difficult,  and  in  young 
subjects  lupus  can  scarcely  be  confounded  with  any  disease  excepting 
hereditary  syphilis.  In  cases  where  the  disease  is  confined  to  the 
larynx  a  diagnosis  can  only  be  reached  by  a  careful  exclusion  of  other 
diseases. 

Lupus  is  to  be  distinguished  from  tubercular  laryngitis  by  the  char- 
acteristics presented  in  the  following  table: 

Lupus  of  the  larynx.  Tubercular  laryngitis. 

Generally  in  young-  adults.  Commonly  in  middle-aged  persons. 

Usually  associated  with  disease  of  Nearly  always  signs  of  pulmonary 

the  face,  and  no  signs  of  pulmonary  dis-  disease, 
ease. 

Absence  of    constitutional    disturb-  Marked  constitutional  disturbance, 
ance. 

Little,  if  any,  pain.  Severe  local  pain. 

Progress  slow  and  may  be  arrested.  Progress  rapid  and  seldom  arrested. 

Ulcers  deeply  destructive.  Ulcer  generally  superficial. 

Lupus  of  the  larynx  is  to  be  distinguished  from  syphilis  as  follows: 


LUPUS   OF  THE  LARYNX. 


453 


Lupus  of  the  .larynx. 
Most  apt  to  occur  in  young  adults. 


No  syphilitic  history. 
No  constitutional  symptoms;  absence 
of  pain. 

Progress  slow;  aggravated  by  anti- 
syphilitic  treatment.  (Brown,  in  the 
third  edition  of  his  work,  p.  429,  re- 
marks that  mercurial  treatment  does 
not  aggravate  true  lupus,  but  he  ap- 
pears to  contradict  this  statement 
on  p.  437  of  the  same.) 


Syphilitic  laryngitis. 

If  of  hereditary  origin,  it  may  occur 
in  children;  otherwise  it  is  most  apt  to 
occur  in  middle  life,  five  or  ten  years 
later  than  the  advent  of  lupus. 

Syphilitic  history. 

May  be  marked  constitutional  symp- 
toms. Frequently  no  pain,  but  this 
symptom  may  be  severe. 

Progress  may  be  rapid,  but  benefit 
or  cure  follows  anti-syphilitic  treat- 
ment. 


.    Between  lupus  and  cancer  of  the  larynx  the  following  are  the  chief 
j)oints  of  difference  : 


Lupus  of  the  larynx. 
Presence  of  the  disease  or  the  scai-s 
which  follow  it  upon  the  face. 
Usually  occurs  in  early  life. 

Slow  progress,  and   may  be  arrested. 
Apt  to  extend  over  several  years. 


But  slight  pain. 

Slight  constitutional  disturbance. 


Cancer  of  the  larynx. 
No  lesions  upon  the  face. 

Appears  visually  after  the  age  of 
forty. 

Comparatively  rapid  progress,  sel- 
dom or  never  arrested,  and  visually  ter- 
minates fatally  within  from  twelve  to 
eighteen  months,  but  sometimes  ex- 
tends over  four  or  five  years. 

Frequently  severe  pain. 

Marked  cachexia,  rapid  emaciation 
and  exhaustion. 


Prognosis. — The  disease  progresses  very  slowly  and  may  last  indefi- 
nitely, without  materially  shortening  the  patient's  existence.  It  is 
certainly  not  dangerous  to  life,  but  sometimes  new  formations  so  ob- 
struct respiration  as  to  demand  tracheotomy.  Any  interference  with 
cicatrices  by  incision  is  liable  to  result  in  renewed  ulceration.  The  dis- 
ease may  sometimes  be  arrested. 

Treatment. — Ferruginous  and  bitter  tonics  and  cod-liver  oil  are 
recommended  internally,  though  their  effects  are  not  very  apparent. 
Chemical  caustics,  of  which  the  solid  silver  nitrate  is  preferable,  have 
been  used,  but  not  very  satisfactorily.  The  galvano-cautery  is  recom- 
mended by  Lennox  Browne  as  the  best  means  of  destroying  the  diseased 
tissue  and  promoting  a  healthy  condition  of  the  parts.  Thorough 
scraping  and  the  application  of  lactic  acid,  as  specially  recommended  by 
Ramon  de  la  Sota  (loc.  tit.)  are  worthy  of  fair  trial.  This  author  also 
lays  stress  upon  strict  hygienic  and  tonic  treatment,  arsenious  acid 
giving  especially  good  results.     Koch's  tuber culine  has  not  been  found 


454 


DISEASES   OF  THE  LARYNA. 


more  valuable   than    other  remedies,  and  its  use    is   not   infrequently 
followed  by  disastrous  consequences. 


LEPRA   OF  THE  LARYNX. 

Lepra  of  the  larynx  is  an  affection  which  attends  some  cases  of  gen- 
eral leprosy  or  elephantiasis,  and  is  characterized  by  inflammation  and 
the  formation  of  nodular  masses  similar  to  those  seen  upon  the  skin. 
These  usually  ulcerate  and  are  a  cause  often  of  dyspnoea  or  hoarseness. 

Anatomical  and  Pathological  Characteristics. — The  disease 
is  attended  by  congestion  of  the  mucous  membrane,  with  uniform  or 
nodular  swelling,  and  considerable  deformity.  In  advanced  cases  ex- 
tensive ulceration   may  have  occurred.     In  some  cases  the  vocal  cords 

have  been  found  thickened  and  of  a  yellowish 
red  color,  while  the  mucous  membrane  of  the 
ary-epiglottic  folds  and  ventricular  bands  has 
been  much  congested,  and  has  the  appearance 
in  some  cases  of  having  been  loosened  from  the 
tissue  beneath.  In  the  only  case  which  has  come 
under  my  observation,  the  mucous  membrane 
was  of  a  reddish  yellow  color,  the  vocal  cords 
had  a  grayish  appearance,  and  the  epiglottis  and 
supra-arytenoid  cartilages  were  thickened,  and 
several  nodules  appeared  on  the  ventricular 
bands,  epiglottis,  and  vocal  cords. 

There  is  a  tendency  of  these  nodules  to 
ulceration,  but,  owing  to  the  slow  progress  of 
the  disease,  this  stage  in  many  cases  is  not 
reached.  In  some  instances  great  thickening  occurs,  and  very  con- 
siderable stenosis  results. 

Etiology. — The  causes  are  the  same  as  those  of  external  lepra, 
which  in  nearly,  if  not  quite,  all  cases  precedes  the  disease  of  the  larynx. 
Symptomatology. — There  are  no  characteristic  symptoms,  but  the 
patient  may  become  hoarse  or  suffer  from  dyspnoea,  according  to  the 
thickening  of  the  laryngeal  walls  or  vocal  cords.  Pain  in  swallowing 
was  only  observed  in  one  out  of  twenty-five  cases  reported  by  Morell 
Mackenzie  {Journal  of  Laryngology,  London,  1887  88).  As  noted  by 
Lennox  Browne,  dyspnoea  is  commonly  an  unimportant  symptom,  even 
in  cases  of  marked  stenosis  ("  Diseases  of  the  Throat,"  third  edition). 

Diagnosis. — The  diagnosis  is  based  upon  the  presence  of  external 
lepra  and  the  abnormal  appearance  of  the  larynx,  as  already  described ; 
also  upon  the  rarity  of  pain  in  speaking  or  swallowing,  even  though 
the  disease  may  be  far  advanced;  and  on  the  infrequency  of  ulceration. 
Prognosis. — The  prognosis  is  unfavorable. 

Treatment. — Tracheotomy  is  rarely  indicated,  but  it  may  be  neces- 
sary if   oedema  of  the   glottis    develops.     No   treatment  has  yet  been 


Fig.  143.— Lepra  of  Larynx. 

Besides  the  irregular  thickening 
of  the  epiglottis  and  ary-epiglot- 
tic folds,  five  distinct  tubercles 
can  be  seen  on  the  vocal  cords 
and  ventricular  band,  and  one  is 
indistinctly  seen  on  the  anterior 
surface  of  the  infra-glottic  por- 
tion of  the  larynx. 


LARYNGITIS   OF  SCARLET  FEVER.  455 

discovered  which  will  surely  relieve  lepra,  but  the  internal  administra- 
tion of  chaulmoogra  oil,  five  to  sixty  drops  daily  in  an  emulsion,  has  ap- 
parently benefited  some  cases.  At  the  same  time  an  inunction  of  an 
ointment  prepared  from  the  same  oil  with  five  or  six  parts  of  lard  should 
be  used.  In  the  single  case  which  I  have  observed,  J.  Kevins  Hyde,  of 
Chicago,  employed  this  remedy  with  apparently  much  benefit  to  the 
patient. 

HYPERTROPHY   OF   THE  LARYNX. 

In  his  work  on  "  Diseases  of  the  Throat  and  Xose,"  J.  Solis  Cohen 
cites  one  instance  in  which  all  of  the  tissues  were  thickened  and  hyper- 
trophied,  but  without  congestion  of  the  parts;  the  obstruction  of  the 
glottis  became  so  great  that  tracheotomy  was  necessary.  !No  cause  was 
known  for  the  disease. 

LARYNGITIS  DUE   TO   SMALL-POX. 

Laryngitis  due  to  small-pox  is  always  secondary  to  the  eruption  upon 
the  skin,  and  may  be  either  mild,  or  severe.  In  the  latter  case,  the  ex- 
udate interferes  with  respiration  in  the  same  way  aa  diphtheritic  mem- 
brane in  the  same  locality,  and  should  be  treated  in  a  similar  manner, 
intubation  or  tracheotomy  being  performed  if  dyspnoea  becomes  urgent. 

LARYNGITIS   OF    MEASLES. 

Most  cases  of  measles  are  attended  by  inflammation  of  the  larynx, 
either  mild  or  severe.  Usually  there  is  simple  catarrhal  inflamma- 
tion in  the  earlier  part  of  the  attack,  which  gradually  passes  away  as 
the  disease  progresses  ;  but  in  some  cases,  just  as  the  eruption  on  the 
skin  is  disappearing  the  larynx  becomes  involved.  This  form  of  in- 
flammation is  generally  very  obstinate  and  may  permanently  impair  the 
voice.  In  some  epidemics  of  measles  there  is  a  peculiar  proneness  to  a 
deposit  of  false  membrane  in  the  larynx,  occurring,  as  a  rule,  from  the 
third  to  the  sixth  day.  It  causes  the  same  symptoms  as  diphtheritic 
laryngitis  and  calls  for  the  same  treatment,  but  unfortunately  the  ma- 
jority of  these  patients  die;  so  great,  indeed,  is  the  mortality  that 
some  authors  have  stated  that  none  of  them  recover  even  after  intuba- 
tion or  tracheotomy.  Intubation  has  seemed  to  be  followed  by  more 
favorable  results  in  this  particular  disease  than  tracheotomy. 

LARYNGITIS   OF   SCARLET  FEVER. 

Laryngitis  of  scarlet  fever  is  a  comparatively  rare  affection  which 
may  be  simple  in  character,  but  is  sometimes  complicated  with  oedema 
of  the  glottis  or  with  a  diphtheritic  exudate.  In  the  latter  case  it 
should  receive  the  same  treatment  as  diphtheritic  laryngitis. 


45G  DISEASES   OF   THE   LARYNX. 


CHRONIC   STENOSIS   OF   THE    LARYNX. 

Chronic  stenosis  of  the  larynx  usually  occurs  in  syphilitic  subjects, 
or  in  persons  who  have  suffered  from  chondritis  or  perichondritis  result- 
ing from  typhoid  fever  or  tuberculosis.  It  is  characterized  by  more  or 
less  alteration  of  the  voice,  and  dyspnoea  in  proportion  to  the  narrowing 
of  the  glottis. 

Anatomical  and  Pathological  Characteristics. — The  obstruc- 
tion usually  occurs  from  vicious  adhesions  or  from  the  contraction  of 
large  cicatrices.  The  chink  of  the  glottis  may  have  various  forms,  and 
in  size  may  vary  from  the  normal  to  a  minute  opening  scarcely  large 
enough  to  permit  the  passage  of  sufficient  air  to  support  life;  the  parts 
are  usually  thickened,  hard,  and  distorted  in  various  ways.  The  vocal 
cords,  ventricular  bands,  or  the  arytenoid  cartilages  may  be  more  or  less 
adherent  to  each  other. 


m** 


Fig.  144. — Syphilitic  Laryngitis.    A.lhe-  Fig.  145.— Syphilitic  Stenosis  of  Larynx. 

sion  of  anterior  portion  of  vocal  cords,  and  Adhesion  of  greater  portion  of  vocal  cords, 

swelling  of  arytenoids. 

Etiology. — The  disease  usually  results  from  syphilis,  but  it  may  fol- 
low inflammations  of  the  cartilage  or  perichondrium  caused  by  wounds, 
typhoid  fever,  or  tuberculosis;  in  exceptional  instances  it  has  been 
caused  by  chronic  catarrhal  laryngitis.  The  obstruction  may  be  caused 
by  submucous  infiltrations  or  hyperchondrosis,  or  two  or  more  of  these 
conditions  may  be  combined. 

Symptomatology. — In  connection  with  the  history  of  one  of  the 
causes  already  mentioned  we  may  find  that  the  larynx  has  become  in- 
volved and  that  the  disease  has  gradually  or  rapidly  progressed  until 
there  is  great  difficulty  in  respiration.  Sometimes  there  has  been  a  sud- 
den amelioration  of  the  inflammatory  symptoms  and  apparent  improve- 
ment of  the  condition,  but  the  difficulty  in  respiration  has  gradually  in- 
creased owing  to  the  contraction  of  the  cicatricial  tissue  which  has  been 
formed.  The  voice  will  be  impaired,  and  respiration  obstructed,  accord- 
ing to  the  part  of  the  larynx  involved  or  to  the  narrowing  of  the  glottis 
present.  Distortion  or  thickening  of  the  larynx  and  narrowing  of  the 
glottis  may  be  seen  upon  a  laryngoscopic  examination. 

Diagnosis. — Chronic  stenosis  of  the  larynx  is  to  be  distinguished 


CHRONIC  STENOSIS  OF  THE  LARYNX.  457 

from  asthma,  compression  of  the  trachea  or  larynx  by  tumors  or  other 
causes,  foreign  bodies  in  the  air  passages,  and  paralysis  of  the  abductors 
of  the  vocal  cords.  The  diagnosis  must  usually  be  based  upon  the  his- 
tory and  the  laryngoscopic  appearances. 

In  asthma,  there  is  a  history  of  sudden  and  repeated  paroxysms  of 
dyspnoea  with  more  or  less  complete  intermissions  or  remissions  of  the 
attack,  instead  of  the  gradually  increasing  obstruction  found  in  laryn- 
geal stenosis;  there  are  many  instead  of  few  bronchial  rales  and  slight, 
if  any,  alteration  of  the  larynx. 

A  history  and  a  laryngoscopic  appearance  entirely  different  belong  to 
foreign  bodies  in  the  larynx. 

We  are  to  diagnosticate  tumors  pressing  on  the  larynx  or  trachea 
by  a  careful  physical  examination  of  the  neck  and  chest.  When  this 
does  not  succeed,  an  inspection  of  the  larynx  enables  us  to  distinguish 
between  this  condition  and  stenosis. 

Dyspnoea,  often  as  pronounced  as  that  of  stenosis,  is  caused  by  pa- 
ralysis of  the  abductors.  Here  again  the  history  must  be  carefully  con- 
sidered, and  upon  inspection  the  position  of  the  cords  near  the  median 
line,  their  slight  movements  with  respiration,  and  the  absence  of  thick- 
ening or  cicatrices,  will  indicate  the  true  nature  of  the  morbid  process. 

Prognosis. — The  voice  is  usually  permanently  lost,  and  the  disease 
progresses  gradually  to  a  fatal  termination  unless  appropriate  treatment 
is  adopted.  By  proper  surgical  procedures,  however,  life  may  be  indefi- 
nitely prolonged,  though  the  patient  often  has  to  wear  a  tracheal  canula 
during  the  rest  of  his  days. 

Teeatmext. — Whatever  the  cause  of  chronic  stenosis,  medicinal 
treatment  alone  is  of  little,  if  any,  avail  in  most  cases,  for  even  when  of 
syphilitic  origin  the  disease  usually  progresses  so  rapidly  that  surgical 
interference  becomes  imperative.  If  dyspnoea  is  great,  it  is  essential 
that  it  should  be  promptly  relieved  by  intubation  or  tracheotomy,  and 
it  is  highly  advisable  that  these  operations  should  be  recommended 
early.  The  anaesthesia  for  tracheotomy  in  these  cases  is  best  obtained 
by  the  hypodermic  injection  of  a  few  drops  of  a  four  per  cent  solution 
of  cocaine  (Form.  140)  along  the  line  of  incision.  If  the  dyspnoea  is  not 
pronounced,  Schrotter's  laryngeal  bougies  may  be  employed  for  gradual 
dilatation,  but  otherwise  tracheotomy  should  be  performed  unle'ss  one  of 
O'Dwyer's  laryngeal  tubes  of  sufficient  size  to  give  the  patient  relief  can 
be  introduced.  After  tracheotomy,  or  when  there  is  no  immediate  dan- 
ger to  life,  dilatation  of  the  parts  should  be  practised  by  some  of  the 
various  methods  recommended  in  standard  works.  The  repeated  and 
persistent  use  of  Schrotter's  bougies,  gradually  increasing  sizes  of  which 
should  be  introduced  two  or  three  times  a  week,  will  sometimes  prove 
successful,  but  the  treatment  is  necessarily  tedious,  and  there  is  much 
liability  to  recurrence  of  the  stricture.  Schrotter's,  Mackenzie's,  or 
Xavratil's    dilators   may  be  employed  with  satisfaction  in  some  cases 


45s 


/> is/-; AsK.s   OF  THE  LARYNX. 


(Morell  Mackenzie's  Diseases  of  the  Throat  and  Xose),  but  when  adhe- 
sions of  the  ventricular  bands  or  vocal  cords  have  occurred,  Whistler's 
cutting  dilator  will  often  be  found  more  satisfactory.      O'Dwyer's  method 


Fig.  146.— Mackenzie's  Laryngeal  Dilator.    A,  Closed  :  B,  open.    The  blades  may  be  separated 
by  turning  the  screw  s,  and  the  extent  of  the  separation  will  be  registered  on  the  dial  d. 

of  intubation  furnishes  an  admirable  means  of  treating  chronic  stenosis 
of  the  larynx.  The  laryngeal  tubes  for  this  purpose  are  similar  to  those 
used  for  croup.  They  are  ten  in  number,  varying  in  size  just  below  the 
head  from  six  to  ten  millimetres  in  lateral  diameter  bv  nine  to  nineteen 


Fig.  147.  —Whistler's  Cctting  Dilator.    A,  Dilator  ready  for  use  ;  B,  knife  protruding ; 
C,  knife  ;  k.  handle  for  protruding  knife. 

millimetres  antero -posteriorly.  Several  cases  have  been  reported  where 
these  have  given  much  satisfaction,  and  I  have  treated  two  with  excellent 
results.  If  the  opening  of  the  glottis  is  very  small,  it  should  be  enlarged 
with  "Whistler's  cutting  dilator,  followed  by  the  laryngeal  tube.  A  tube 
which  can  be  easily  introduced  should  be  worn  for  a  few  days  at  first, 


CHRONIC  STENOSIS  OF  THE  LARYNX. 


459 


being  succeeded  by  larger  sizes  from  time  to  time  as  rapidly  as  may  be 
without  giving  the  patient  discomfort.  When  the  full  size  has  been 
reached,  it  should  be  worn  for  several  weeks,  by  which  time  in  most  cases 
the  tendency  to  recurrence  of  the  trouble  has  disappeared ;  but  if  con- 
traction occurs,  the  tube  should  be  worn  occasionally  to  keep  the  glottis 


Fig.  148.— Tube  for  Laryngotracheal  Stenosis.  A,  Tubes  in  position;  B,  outer  tube  which 
passes  up  to  the  larynx;  C,  middle  tube  which  passes  through  the  fenestra,  in  the  outer  tube,  into 
the  trachea;  D,  inner  tube  of  sufficient  length  to  relieve  stenosis  low  down  the  trachea;  E,  valve 
which  opens  on  inspiration  and  closes  on  phonation  or  expiration. 

open.  Whatever  treatment  is  adopted,  the  voice  is  apt  to  be  permanently 
impaired.  It  has  seemed  to  me  that  continual  wearing  of  an  O'Dwyer's 
tube  is  more  liable  to  injure  the  voice  than  intermittent  dilatation. 
Possibly  these  tubes  might  be  used  for  much  shorter  periods  with  equally 
good  results  in  keeping  the  glottis  open,  and  without  so  much  injury  to 
the  voice,  but  this  is  a  matter  to  be  determined  by  future  experience. 

After  tracheotomy  when  the  lower  portion  of  the  larynx  or  upper 
part  of  the  trachea  become  obstructed  by  vegetations  or  cicatricial  con- 
tractions above  the  canula,  these  must  be  removed.  The  operation  will 
be  facilitated  by  the  punch  forceps  spoken  of  when  treating  of  post-tra- 
cheotomic  vegetations  (Fig.  178).  The  air  passage  may  then  be  kept 
open  by  the  combination  tube  shown  in  Fig.  148.  This  tube  allows  the 
patient  to  talk,  and  may  be  worn  as  long  as  necessary. 

Sometimes  the  constant  tendency  to  contraction  will  necessitate  its 
retention  during  the  remainder  of  the  patient's  life. 


460  DISEASES  OF   THE  LARYNX. 


STENOSIS  OF  THE  TRACHEA. 

The  close  relation  of  the  larynx  and  the  trachea  in  some  sense  com- 
pels the  discussion  of  tracheal  diseases  with  those  of  the  larynx. 

Stricture  of  the  trachea  is  a  condition  frequently,  though  not  con- 
stantly associated  with  stricture  of  the  larynx.  .  It  is  characterized  by 
paroxysmal  cough  and  dyspnoea,  aggravated  from  time  to  time  by 
congestion  and  swelling  of  the  parts  or  the  collection  of  mucus.  The 
obstruction,  which  may  occur  at  any  part  of  the  trachea,  usually  results 
from  cicatrizations  of  syphilitic  ulcers  or  from  comjiression  by  intra- 
thoracic tumors.  The  diagnosis  can  only  be  made  after  careful  physi- 
cal exploration  of  the  throat  and  chest,  and  a  painstaking  laryngoscopic 
examination  whereby  obstructions  above  the  vocal  cords  are  eliminated. 

The  prognosis  is  always  unfavorable  when  the  lesion  is  too  low  to  be 
relieved  by  tracheotomy.  In  syphilitic  cases,  vigorous  use  of  the  iodides 
has  sometimes  given  great  relief.  Dilatation  through  the  larynx  by 
means  of  long  flexible  catheters  has  been  recommended.  The  best  results 
are  to  be  expected  from  tracheotomy  with  subsequent  dilatation  and  the 
wearing  of  a  long,  flexible  tracheotomy  tube. 

TRACHEITIS. 

Tracheitis,  is  an  inflammation  of  the  mucous  membrane  of  the  trachea, 
which  may  be  either  acute  or  chronic.  It  sometimes  occurs  indepen- 
dently, but  is  usually  associated  with  laryngitis  or  bronchitis.  The  dis- 
ease is  generally  mild,  but  severe  cases  sometimes  occur. 

Anatomical  and  Pathological  Characteristics. — In  the  acute 
cases  the  mucous  membrane  may  be  red  and  swollen,  so  that  the  inter- 
spaces between  the  cartilages  cannot  be  seen.  In  chronic  cases  the 
membrane  is  usually  slightly  swollen  and  of  a  deep  pink  color,  and  the 
intercartilaginous  spaces  are  not  very  distinct  or  may  be  invisible;  there 
are  some  cases,  however,  in  which  post-mortem  examination  reveals  no 
congestion.  In  chronic  cases  masses  of  mucus  may  often  be  seen  ad- 
hering to  the  surface,  and  rarely,  ulcers  are  present.  A  peculiar  form 
of  this  disease  is  sometimes  met  with  in  which  the  mucous  membrane 
is  covered  by  desiccated  and  decayed  secretions  similar  to  those  found 
in  the  nasal  cavity  in  ozcata. 

Etiology. — The  causes  of  tracheitis  are  the  same  as  those  of  laryn- 
gitis and  bronchitis.     Chronic  cases  are  frequently  due  to  rheumatism. 

Symptomatology. — In  acute  cases  the  patient  generally  complains 
of  a  sense  of  soreness  or  rawness  in  the  superior  sternal  region  or  at  the 
upper  portion  of  the  trachea,  with  tickling  or  itching  of  the  part  and 
frequent  cough.  During  the  first  few  days  the  expectoration  is  scanty, 
thick,  and  tenacious;  but  as  the  disease  progresses  toward  recovery,  it 
becomes  muco-purulent  as  in  ordinary  cases  of  subacute  bronchitis. 


TRACHEITIS.  401 

In  the  chronic  disease  there  is  sometimes  localized  pain  over  a  small 
portion  of  the  trachea,  but  usuall}*  simply  a  sense  of  discomfort  due  to 
swelling  of  the  mucous  membrane,  dryness,  or  a  collection  of  mucus 
upon  its  surface.  Sometimes  the  tickling  sensation  is  very  annoying. 
These  symptoms  are  associated  with  a  hacking  or  hemming  cough  and 
expectoration  of  small  quantities  of  mucus  usually  discolored  by  dust. 
Occasionally  the  cough  is  paroxysmal.  In  many  cases  there  is  slight 
hoarseness,  or  simply  a  loss  of  control  over  the  voice  on  attempting  to 
sing.     The  general  health  is  not  impaired. 

Upon  examination  of  the  chest,  mucous  or  sonorous  rales  are  some- 
times found  over  the  trachea  alone,  or  transmitted  over  the  entire 
thorax.  When  the  mucous  membrane  is  dry  and  the  secretions  are  de- 
composing, the  patient  is  greatly  annoyed  by  constant  efforts  to  clear  the 
trachea,  and  by  an  offensive  odor  similar  to  that  of  ozama.  In  some  of 
these  cases  the  crusts  collect  just  beneath  the  glottis  and  may  give  rise 
to  spasm  of  the  larynx;  in  others  the  symptoms  are  very  similar  to  those 
of  asthma.  Laryngoscopic  inspection  will  reveal  the  condition  already 
mentioned. 

Diagnosis. — The  disease  is  readily  distinguished  from  laryngitis 
and  bronchitis  by  laryngoscopic  examination,  and  physical  exploration 
of  the  chest. 

Prognosis. — Acute  tracheitis  usually  subsides  in  from  five  to  four- 
teen days.  The  chronic  form  may  last  for  several  months  or  even  years. 
The  variety  attended  by  drying  of  the  secretions  is  peculiarly  obstinate. 
Neither  form  of  the  disease  is  considered  serious;  and  the  common  fear 
of  patients  that  it  may  extend  to  the  lungs,  causing  phthisis,  is  appar- 
ently without  foundation.  There  are  some  cases,  associated  with  con- 
sumption, but  this  appears  to  be  accidental. 

Treatment. — The  acute  cases  may  be  given  the  same  local  treat- 
ment as  acute  laryngitis,  and  the  internal  remedies  suited  to  acute 
bronchitis.  At  the  same  time,  cold  compresses  over  the  chest  in  the 
earlier  part  of  the  attack,  and  hot  compresses  later,  will  often  be  found 
beneficial.  The  patient  should  be  kept  in  as  equable  temperature  as 
possible,  and  should  avoid  exposure.  In  the  ordinary  chronic  cases 
treatment  similar  to  that  employed  in  chronic  bronchitis  is  applicable, 
but  the  greatest  benefit  will  be  derived  from  local  applications.  Sina- 
pisms or  blisters  over  the  sternum  are  sometimes  efficient. 

Whenever  syphilis  exists,  or  the  rheumatic,  gouty,  or  dartrous  di- 
athesis is  present,  these  should  receive  first  attention.  The  local  appli- 
cations which  have  been  found  most  beneficial  consist  of  inhalations 
of  ammonium  chloride  with  oil  of  tar  or  eucalyptol,  and  the  application 
of  various  astringent  sprays,  and  stimulating  powders.  It  is  difficult  to 
apply  a  spray  to  the  trachea  because  the  glottis  will  close  as  soon  as  the 
application  touches  the  larynx,  but  it  may  sometimes  be  accomplished 
by  directing  the  patient  to  cough  while  the  spray  is  being  thrown  in 


462  DISEASE*   <>F  THE  LARYNX. 

quite  forcibly.  The  sprays  which  I  usually  employ  consist  of  solutions 
of  zinc  sulphate  or  chloride  gr.  ii.  to  x.  ad  3  i.,  the  stronger  of  these 
being  contra-indicated  unless  the  larynx  is  also  involved.  In  any  case  the 
patient  should  not  experience  unpleasant  sensations  for  more  than  half 
an  hour  or  at  most  an  hour  after  the  application. 

Some  physicians  favor  injecting  stimulating  solutions  with  a  syringe. 
Powders  have  given  me  the  most  satisfaction  in  the  treatment  of  tra- 
cheitis, as  they  can  be  applied  accurately  and  will  remain  in  contact 
with  the  parts  longer  than  solutions.  These  are  used  two  or  three  times 
a  week,  beginning  with  mild  applications,  and  gradually  increasing  the 
strength  as  found  necessary  to  produce  sufficient  stimulation.  They  are 
applied  while  the  glottis  is  wide  open  by  means  of  a  bent  glass  tube  and 
an  ordinary  insufflator.  Iodol  usually  has  a  salutary  influence  upon 
the  inflamed  mucous  membrane,  and  many  patients  experience  speedy 
relief;  from  half  a  grain  to  two  grains  may  be  used  at  each  sitting.  A 
slightly  more  stimulating  powder,  and  one  that  answers  a  good  purpo.se 
in  some  cases,  consists  of  equal  parts  of  iodol  and  boric  acid.  Where 
still  more  stimulation  of  the  parts  is  desired,  I  usually  combine  with 
the  iodol  or  the  boric  acid  from  five  to  fifteen  per  cent  of  alum 
thoroughly  triturated  with  sugar  of  milk.  Bismuth,  gum  benzoin,  and 
other  powders  are  occasionally  used,  but  the  three  already  mentioned 
generally  work  satisfactorily.  Menthol  may  be  used  in  the  same  man- 
ner, but  it  has  no  specially  beneficial  effect. 

Treatment  of  the  fetid  form  is  eminently  unsatisfactory.  Where 
the  crusts  collect  close  beneath  the  glottis  so  as  to  cause  spasm  of  the 
larynx,  inhalations  of  ammonium  chloride  or  carbonate,  or  sodium  car- 
bonate, with  glycerin  and  water  by  means  of  the  steam  atomizer,  have 
proved  beneficial,  the  strength  being  regulated  by  the  sensations  of  the 
patient.  I  have  employed  a  great  variety  of  substances  and  have  had 
the  patient  use  many  different  remedies  at  home,  but  most  drugs 
seem  to  have  no  influence  in  separating  the  incrustations  or  in  limiting 
their  formation.  The  most  satisfactory  results  have  been  obtained 
from  the  frequent  inhalation  of  oil  of  mustard  in  combination  with 
alcohol  in  proportion  of  about  i\[\.  ad?i.;  a  small  quantity  of  this 
two  or  three  times  daily  is  poured  upon  the  handkerchief  and  in- 
haled by  the  patient,  with  the  result  of  enabling  him  more  readily  to 
clear  the  trachea  and  finally  of  greatly  decreasing  the  collection  of  secre- 
tions and  the  offensive  odor. 


CHAPTER   XXVII. 

DISEASES   OF   THE   LABYNX.— Continued. 

MORBID   GROWTHS  IN   THE   LARYNX. 

Laryngeal  tumors  include  several  varieties  of  morbid  growths  sim- 
ilar to  those  found  in  many  other  portions  of  the  body.  They  are 
commonly  benign,  and  of  these  the  papillary  form  constitutes  about 
seventy-five  per  cent.  Next  in  order  of  frequency,  respectively,  come  fib- 
rous tumors  and  fibro-cellular  growths,  the  latter  constituting  only 
about  five  per  cent  of  the  whole  number  of  intra-laryngeal  tumors. 
Following  these  we  find  cystic,  lipomatous,  and  malignant  epithelial 
and  sarcomatous  growths;  cartilaginous  tumors  are  among  the  most 
infrequent.  Intra-laryngeal  tumors  are  usually  characterized  by  dys- 
phonia  or  complete  loss  of  voice,  often  by  dyspnoea  and  occasionally  by 
dysphagia.  They  occur  most  frequently  in  middle  aged  men,  but  they 
occasionally  appear  in  advanced  age,  and  are  seen  in  children,  sometimes 
being  of  congenital  origin.  Previous  to  the  development  of  laryngos- 
copy in  1857,  only  seventy  laryngeal  tumors  had  been  recorded.  Sub- 
sequently, up  to  the  year  1871,  about  three  hundred  were  observed,  ac- 
cording to  Morell  Mackenzie;  but  since  then  the  number  has  run 
rapidly  into  the  thousands,  and  many  of  these  have  been  cured  by  intra- 
laryngeal  operations. 

Anatomical  and  Pathological  Characteristics. — The  larynx  is 
usually  more  or  less  congested,  and  the  tumor  may  spring  from  any  por- 
tion of  the  organ,  though  certain  parts  are  especially  liable  to  certain 
varieties  of  morbid  growth.  The  appearance  of  the  tumor  and  its  path- 
ological peculiarities  depend  upon  its  character,  size,  and  location.  Their 
microscopical  appearance  is  not  unlike  that  of  similar  neoplasms  in 
other  parts  of  the  body,  but  it  frequently  happens  that  it  is  impossible 
by  such  examination  to  determine  the  true  character  of  the  growth. 

Etiology. — Benign  tumors  nearly  always  have  their  origin  in  con- 
tinued local  hyperemia;  their  causation  is  therefore  often  the  same  as 
that  of  chronic  laryngitis.  Cohen  believes  that  they  are  not  infre- 
quently caused  by  catarrhal  inflammation,  due  to  the  exanthemata,  or  to 
that  resulting  from  croup,  diphtheria,  pertussis,  or  the  inhalation  of 
irritating  substances;  he  also  shows  that  they  sometimes  occur  in  per- 
sons suffering  from  syphilis  or  tuberculosis  (Diseases  of  the  Throat 
and  Nasal  Passages).     Morell  Mackenzie,  on  the  other  hand,  states  that 


4i  14 


DISEASES   <>F  THE  LARYNX. 


neither  syphilis  nor  phthisis  is  a  predisposing  cause,  though  he  admits 
that  both  may  give  rise  to  false  excrescences  or  outgrowths  (Diseases  of 
the  Throat  and  Nose,  Vol.  I).  He  attributes  laryngeal  neoplasms  in 
many  eases  to  the  professional  use  of  the  voice. 

Symptomatology. — The  symptoms  of  a  tumor  in  the  larynx  depend 
upon  its  size  and  position,  and  are  essentially  the  same  whether  it  is 
benign  or  malignant.  The  usual  symptoms,  which  vary,  of  course,  with 
the  size  of  the  growth  and  the  part  of  the  larynx  involved,  are:  cough, 
dyspnoea,  dysphonia  or  aphonia,  dysphagia,  and  occasionally  pain. 

Cough  is  not  apt  to  be  troublesome  unless  the  growth  is  large  or  in- 
volves the  glottis,  or  unless  it  is  attended  by  bleeding;  that  which  does 

occur  is  often  paroxysmal  and  may  be 
of  a  croupy  character. 

Dysphonia  or  aphonia,  hoarseness,  or 
even  complete  loss  of  the  voice  occur 
when  the  growth  is  located  on  the  vocal 
cords,  or  Avhen  its  position  or  the  con- 
current inflammation  interferes  with 
their  vibration.  It  is  surprising  how 
small  a  growth  located  on  the  edge  of 
the  cord  will  cause  hoarseness  while 
large  tumors  differently  situated  some- 
times but  slightly  interfere  with  pho na- 
tion. Sometimes  the  aphonia  is  inter- 
mittent and  it  may  disappear  or  change 
with  alteration  of  the  patient's  position. 
Dyspnoea  occurs  whenever  the  neo- 
plasm is  sufficiently  large  to  materially 
obstruct  the  respiratory  passages. 

Dysphagia  is  not  a  common  symp- 
tom, but  it  may  occur  when  the  tumor 
involves  the  epiglottis  or  posterior  laryngeal  wall,  or  when  by  its  size  it 
encroaches  on  the  pharynx.  This  symptom  is  more  likely  to  be  present 
in  malignant  growths. 

Pain  is  not  a  common  symptom  in  benign  growths,  although  patients 
frequently  complain  of  a  sense  of  aching  or  discomfort,  or  the  sensation 
as  of  a  foreign  body  in  the  throat.  Occasionally,  even  with  small  tumors 
on  the  vocal  cords,  patients  experience  slight  pain,  especially  upon  deg- 
lutition. Severe  paroxysms  of  pain  are  not  uncommon  in  malignant 
growths,  though  even  with  these  it  is  frequently  absent.  In  adults  a 
laryngoscopic  examination  will  usually  at  once  reveal  the  presence  of  a 
morbid  growth,  but  laryngoscopy  is  frequently  difficult,  and  sometimes 
impossible,  in  young  children,  especially  in  those  less  than  six  years  of 
age.  By  forcibly  pressing  the  tongue  downward  and  forward  with 
a  tongue  depressor  similar  to  that  shown   in  Fig.   140,  a  good    view 


Fig.  149.— Mount  Bleyer's  Tongue 
Depressor  Q£  siz^  > 


BENIGN  TUMORS  OF  THE  LARYNX.  465 

may  commonly  be  obtained  even  in  rebellious  children.  In  young 
subjects  the  larynx  can  be  readily  reached  by  the  finger,  and  it  is  often 
easy  to  feel  the  growth,  provided  it  is  located  above  the  cords.  It  is  im- 
possible to  be  certain  of  the  true  character  of  a  tumor  until  it  has  been 
subjected  to  a  microscopic  examination,  and  even  then  the  diagnosis 
may  remain  doubtful,  for  sometimes  laryngeal  growths  of  malignant 
histological  appearance  possess  a  non-malignant  history  from  beginning 
to  end.  Nevertheless,  in  most  cases,  inspection  of  the  larynx  will  enable 
the  physician  to  practically  determine  the  true  nature  of  the  growth. 


BEXIGX   TUMOES    OF   THE    LABYNX. 

Symptomatology. — The  most  common  symptom  of  these  growths 
consists  of  alteration  of  the  voice,  though  this  is  not  invariably  present. 
A  growth  upon  the  vocal  cord  usually  causes  hoarseness  or  aphonia, 
sometimes  more  marked  from  small  tumors  than  from  large  ones. 
Growths  below  the  cords  usually  affect  the  voice  by  being  forced  upward 


i£*r " 


./ 


Fig.  150.— Papilloma  of  Right  Vocal  Cord.        Fig.  151.— Papilloma  of  Larynx.    Supra-glottic. 

during  expiration.  Those  upon  the  ventricular  bands  usually  cause  no 
alteration  in  the  intonation.  Tumors  upon  the  epiglottis  and  ary-epiglot- 
tic  folds  do  not  usually  alter  the  voice  unless  they  become  very  large. 

Cough  is  not  a  common  symptom,  but  it  sometimes  becomes  very  an- 
noying. Dyspnoea  is  present  in  only  a  small  proportion  of  cases,  usually 
being  inspiratory  and  sometimes  paroxysmal.  According  to  Morell 
Mackenzie,  these  paroxysmal  attacks  are  due  to  sudden  swelling  of  the 
mucous  membrane  in  most  cases,  but  occasionally  to  an  unusual  posi- 
tion of  the  growth.  According  to  Lewin,  if  the  inspiration  is  noisy  and 
stridulous  the  growth  is  probably  above  the  cords  {Deutsche  Klinik, 
1862).  If  interference  with  expiration  occurs,  the  tumor  is  usually  be- 
low the  cords.     Dysphagia  is  much  less  frequent  than  dyspnoea. 

Papillomata  are  usually  located  on  the  upper  surface  or  on  the  free 
margin  of  the  vocal  cord,  but  they  may  occur  in  other  portions  of  the 
larynx.  They  are  generally  of  a  light  pink  color  but  may  be  white  or 
even  red.  They  usually  have  an  irregular,  cauliflower  or  raspberry  like 
surface,  and  vary  in  size  from  a  few  millimetres  in  diameter  to  a  mass 
large  enough  to  completely  occlude  the  larynx  They  are  sometimes 
pedunculated,  but  most  commonly  they  spring  from  a  broad  base;  they 
3° 


400 


DISEASES   OF  THE  LABYNA". 


are  generally  single  but  not  infrequently  multiple  (Figs.  153,  154). 
These  tumors  are  usually  soft  and  may  be  readily  crushed  or  torn  off 
with  forceps,  but  sometimes  they  are  quite  firm. 

Fibromata  are  usually  observed  as  small,  round  or  oval  pedunculated 
growths  (Fig.  155)  of  a  grayish  or  reddish  color,  and  are  most  frequently 
attached  near  the  anterior  extremity  of  the  vocal  cords.  They  vary  in 
size  from  a  pin's  head  to  ten  or  fifteen  millimetres  in  diameter,  though 


Fig.  152.— Papilloma  of  Vocal  Cords. 


Fig.  153.—  Papilloma  of  Vocal  Cords. 


they  seldom  exceed  the  size  of  large  pea.  The  surface  of  these  tumors 
is  usually  smooth,  but  it  may  be  rough  and  irregular;  they  are  firm  and 
resisting  when  touched  with  the  probe.  They  are  generally,  though 
not  invariably,  single  and  pedunculated. 

Fibro-cellular  tumors  consist  of  more  or  less  perfectly  devel- 
oped fibrous  growths,  having  a  serous  like  fluid  diffused  through  their 
substance  (Fig.  150).    They  are  small,  pyriform  or  globular  growths  hav- 


Fig.  154.— Papilloma  of  Larynx 


Fig.  155.— Fibroma  of  Left  Vocal  Cord. 


ing  a  smooth  or  slightly  irregular  surface  of  a  pale  pink  or  reddish  hue. 
They  are  usually  pedunculated,  but  may  be  sessile,  and  are  generally 
attached  to  the  vocal  cords  or  laryngeal  surface  of  the  epiglottis. 

Myxomata,  or  true  mucous  polypi,  are  seldom  found  in  the  larynx. 
They  are  generally  of  a  light  gray  or  pinkish  color,  commonly  trans- 
lucent; the  surface  may  appear  smooth  or  irregular,  and  they  are  soft 
to  the  touch. 

Cystic  growths,  when  found  in  the  larynx,  vary  in  color  from  a 
light  yellow  to  a  red,  and  are  usually  surrounded  by  a  zone  of  congested 
mucous  membrane.     They  are  round  or  oval  in  form,  and  generally  arise 


BENIGN  TUMORS  OF  THE  LARYNY. 


467 


from  the  epiglottis  or  ventricle  of  Morgagni.  They  vary  in  size  from 
three  to  fifteen  millimetres  in  diameter.  They  are  ordinarily  filled  with 
a  semi-fluid,  sebaceous  like  material. 


Fig.  156.— Fibko-Cellular  Tumor 
on  Right  Vocal  Cord. 


Fig.  157 


-Cystic  Tumor  affecting  Base  of 
Left  Side  of  Epiglottis. 


Fasciculated  saecomata,  adenomata  and  lipomata  possess  no 
characteristic  appearances,  and  are  extremely  rare.  They  may  spring 
from  the  epiglottis  or  mucous  membrane  over  the  arytenoid  cartilages 
or  other  parts  outside  the  larynx,  but  not  usually  from  within  it. 


Fig.  158.— Cystic  Growth  in  Right 
Ventricular  Band. 


Fig.  159. — Cyst  of  Epiglottis 
(Mackenzie). 


Cartilaginous  tumors  are  extremely  rare.  Fig.  162  illustrates 
one  of  this  variety  growing  from  the  lower  part  of  the  thyroid  cartilage. 
It  had  a  smooth  mucous  covering,  was  of  a  yellowish  color  and  carti- 
laginous consistence. 


Fig.  160.— Adenoid  Tumor  of  the  Larynx. 


Fig.  161.— Adenoid  Tumor  of  Larynx, 
involving  Ventricle  of  Morgagni. 


Angiomata  or  vascular  tumors  are  also  very  rare.  They  are  dark, 
blackberry-like  in  color  and  appearance.  They  are  soft,  and  bleed  easily 
when  touched,  and  may  give  rise  to  severe  hemorrhage  if  removed. 

Diagnosis. — Granulation  tissue  such  as  is  frequently  found  in  tu- 
bercular laryngitis  might  closely  resemble  papillary  growths,  but  it  is 


468 


DISEASES   OF  THE  LARYNX. 


usually  lighter  in  color  and  softer  in  consistence,  and  more  or  less  cov- 
ered by  the  same  secretions  which  are  seen  upon  the  neighboring  ulcer- 
ated surfaces.  The  affections  most  likely  to  be  mistaken  for  benign 
growths  of  the  larynx  are  syphilitic  or  tubercular  laryngitis,  lepra,  lupus, 


Fig.  162. — Cartilaginous 
Tumor  of  Larynx.  Situated 
just  below  the  vocal  cord 


Fig.  163.— Vascular  Tcmor  of 
Larynx,  involving  Surface  of 
Right  Vocal  Cord. 


Fig.  164.— Vascular  Tumor  of 
Larynx.  Of  a  deep  livid  color 
and  raspberry  like  surface 


fibrous,  cartilaginous,  or  lymphoid  outgrowths,  eversion  of  the  ventricles 
of  the  larynx,  and  malignant  tumors. 

Benign  growths  of  the  larynx  are  distinguished  from  syphilitic  con- 
dylomata as  follows: 


Benign  growths  of  the  larynx. 

Commonly  in  middle  and  advanced 
life;  occasionally  in  children. 

History  of  continued  local  hyperae- 
mia. 

Usually  found  upon  the  vocal  cords 
or  ventricular  bands. 

Distinct  line  of  demarcation  between 
growth  and  surroundings. 

Usually  no  ulceration  present. 

Operative  measures  usually  neces- 
sarv. 


Syphilitic  condylomata  of  the 

larynx. 
Commonly  in  early  and  middle  life. 

History  of  infection;  appearance  five 
or  six  weeks  after  inoculation. 

Usually  situated  at  back  part  of  the 
larynx. 

Xo  distinct  line  of  demarcation. 

Ulceration  frequently  present. 

Rapid  disappearance  under  anti- 
syphilitic  treatment  and  use  of  local 
astringents. 


Benign  growths  of  the  larynx  are   distinguished   from   tubercular 
laryngitis  as  follows : 


Benign  growths  of  the  larynx. 
No  cachexia  or  pulmonary  disease. 


Absence  of  pain. 

Hyperemia  or  normal  color  of  mu- 
cous membrane ;  no  ulceration  or  pe- 
culiar swelling. 

Benign  papillary  tumors  less  sessile 
than  tubercular  granulations:  no  pu- 
rulent secretion. 


TUEERCULAR   LARYNGITIS. 

Usually  grave  constitutional  symp- 
toms and  signs  of  associated  pulmo- 
nary affection. 

Usually  painful. 

Pallor  of  the  mucous  membrane, 
with  peculiar  swelling  of  the  aryte- 
noids and  ulceration. 

Tubercular  fungous  granulations  are 
of  light  color:  appear  as  thickenings 
rather  than  outgrowths:  and  are  as- 
sociated with  ulceration  and  purulent 
secretion. 


BENI&N  TUMORS  OF  THE  LARYNX.  469 

Lepra  of  the  larynx  is  associated  with  similar  manifestations  upon 
the  skin.  The  epiglottis  and  lower  parts  of  the  larynx  are  likely  to 
be  swollen  and  nodular,  but  no  distinct  tumors  are  present. 

Thickening  and  nodular  outgrowths,  which  are  generally  soon  fol- 
lowed by  ulceration,  are  caused  by  lupus  /  and  in  nearly,  if  not  quite  all 
cases  the  disease  in  the  larynx  is  preceded  by  ulceration  on  the  face  or 
in  the  fauces,  which  will  materially  aid  in  the  diagnosis. 

We  can  recognize  outgrowths  of  various  character  as  merely  thicken- 
ing of  the  tissues,  lacking  the  distinct  demarcation  of  true  tumors. 

"We  might  possibly  mistake  eversion  of  the  ventricle  of  the  larynx  for 
a  tumor,  but  the  condition  is  so  extremely  rare  that  the  error  is  not 
likely  to  occur. 

Generally  malignant  tumors  may  be  recognized  through  being  more 
thoroughly  blended  with  the  surrounding  tissues,  which  become  irregu- 
larly swollen  and  thickened  so  that  the  tumor  does  not  stand  out  dis- 
tinctly, an  appearance  very  unlike  that  of  benign  growths.  In  some 
cases  where  diagnosis  by  inspection  is  extremely  difficult,  the  presence 
of  pain,  the  constitutional  symptoms  apparent  in  the  later  stages,  the 
ulceration  of  the  growth  and  the  microscopic  appearances,  must  all  be 
considered  in  drawing  a  conclusion. 

Prognosis. — The  growths  tend  to  increase  in  size  slowly  or  rapidly, 
according  to  their  character,  except  in  very  rare  instances  of  papillomata 
where  sjDontaneous  atrophy  or  expulsion  may  take  place. 

Growths  in  the  larynx  which  cannot  be  removed  are  always  danger- 
ous, especially  in  young  children,  in  whom  smallness  of  the  organ  and 
disposition  to  spasm  enhance  the  danger.  In  children,  these  tumors  are 
more  dangerous  than  in  adults,  because  of  the  difficulty  of  endo-laryngeal 
operations,  and  the  less  favorable  results  of  tracheotomy;  an  operation 
which  if  successful,  removes  one  of  the  serious  dangers  by  averting 
the  tendency  to  suffocation.  This  operation,  however,  is  often  grave  in 
young  children,  and  is  far  from  being  devoid  of  danger  in  adults;  for 
in  either,  a  fatal  bronchitis  not  infrequently  supervenes.  As  regards 
the  voice,  the  prognosis  is  favorable  where  the  growth  is  single  and 
pedunculated  and  an  endo-laryngeal  operation  can  be  performed.  In 
the  opposite  condition  the  prognosis  is  necessarily  less  favorable.  Some 
forms  of  papillomata  show  a  strong  disposition  to  reproduction  after 
removal.  With  the  exception  of  sarcomata  or  carcinomata,  other  laryn- 
geal growths  seldom  recur. 

Treatment. — Small  growths  in  the  larynx  situated  above  the  vocal 
cords  commonly  cause  little  or  no  inconvenience,  and  often,  especially 
when  fibrous,  enlarge  but  slowly.  In  such  instances,  active  inter- 
ference is  unnecessary,  provided  the  growth  can  be  inspected  once  or 
twice  a  year.  Even  when  the  tumor  is  situated  upon  the  cords,  causing 
more  or  less  complete  aphonia,  it  is  frequently  wise  not  to  interfere, 
especially  in  the  aged  or  in  those  whose  occupation  renders  the  voice 


47U  DISEASES    OF   THE   LARYNX. 

relatively  of  little  importance.  Even  the  most  skilful])-  performed 
endo-laryngeal  operations  are  not  entirely  devoid  of  danger,  and  occa- 
sionally they  excite  sufficient  inflammation  of  the  soft  parts,  cartilages, 
or  perichondrium,  to  render  tracheotomy  necessary;  and  it  is  possible, 
though  not  probable,  that  the  irritation  of  frequent  attempts  at  removal 
may  cause  a  benign  growth  to  take  on  malignancy. 

Palliative  treatment  consists  in  the  application  of  various  astringent 
remedies,  which  sometimes  apparently  retard  the  growth;  and  where 
respiration  is  seriously  impeded  in  the  performance  of  tracheotomy  or 
the  introduction  of  an  O'Dwyer's  laryngeal  tube.  The  latter  is  to  be 
first  recommended  in  most  cases,  because  the  pressure  which  it  exerts 
may  possibly  cause  atrophy  of  the  growth,  and  the  relief  of  dyspnoea  is 
usually  complete  except  in  cases  of  large  tumors  at  the  upper  part  of 
the  larynx,  which  may  fall  over  the  opening  in  the  tube. 

Radical  treatment  for  the  destruction  or  the  removal  of  the  growth 
should  in  nearly  all  cases  be  carried  out  through  the  natural  passage  by 
the  endo-laryngeal  method;  but  in  exceptional  instances  laryngotomy 
or  a  combination  of  the  exo-laryngeal  and  endo-laryngeal  methods  may 
be  required.  The  endo-laryngeal  removal  of  neoplasms  may  be  accom- 
plished by  chemical  or  mechanical  means,  or  by  a  combination  of  the 
two.  Local  treatment  by  astringents  or  mild  caustics  is  sometimes  ben- 
eficial, especially  in  removing  concomitant  inflammation,  and  so  possibly 
preventing  increased  growth  of  the  tumor.  Mild  caustics  have  little 
effect  upon  the  growth  itself,  but  accurate  applications  of  escharotics, 
especially  chromic  acid,  are  not  infrequently  followed  by  most  satisfac- 
tory results.  The  same  may  be  said  of  the  galvano-cautery  and,  with 
less  confidence,  of  solid  silver  nitrate.  Usually  before  any  endo-laryn- 
geal operation  is  commenced  for  the  removal  of  growths,  the  parts  should 
be  thoroughly  anaesthetized  by  several  applications,  by  spray  or  swab,  of 
a  ten  per  cent  to  twenty-five  per  cent  solution  of  cocaine  or  the  solution 
recommended  for  anaesthetizing  the  nasal  mucous  membrane  (Form. 
14-°)).  This  done,  silver  nitrate  or  chromic  acid  fused  upon  the  end  of 
an  aluminium  probe,  and  protected  to  prevent  contact  with  other  por- 
tions of  the  larynx,  should  be  accurately  applied  to  the  growth  with 
the  aid  of  the  laryngoscope.  The  skilful  laryngologist  may  sometimes 
apply  the  escharotic  without  injuring  other  parts,  by  means  of  an  un- 
guarded probe,  but  it  is  safer  to  employ  some  of  the  various  instruments  de- 
signed to  prevent  accidental  contacts.  The  simplest,  and  to  me  the  most 
satisfactory  instrument  is  a  comparatively  stiff  aluminium-wire  probe, 
over  which  has  been  slipped  a  section  of  small  rubber  tubing  about 
half  an  inch  in  length;  about  this  tubing  is  tied,  with  a  slip-knot,  a  piece 
of  silk  thread  which  is  then  wound  about  the  stem  and  carried  up  to  the 
handle,  thus  preventing  the  possibility  of  the  tube  slipping  off  into  the 
trachea.  The  tube  is  slipped  upward  upon  the  stem  while  the  caustic 
is  being  fused  upon  the  probe  and  is  pushed  back  to  the  end  of  the  in- 


BENIGN  TUMORS  OF  THE  LARYNX. 


471 


strument  when  it  has  cooled.  When  it  is  desired  to  cauterize  with  the 
end  of  the  probe  only,  the  rubber  tube  is  pushed  down  far  enough  to 
completely  protect  the  caustic,  for  as  the  instrument  is  pressed  upon 
the  growth  the  elasticity  of  the  rubber  will  allow  the  end  to  protrude 
sufficiently.     If,  however,  it  is  desired  to  touch  the  tumor  with  the  side 


Fig.  165— Common  Laryngeal  Forceps  Qi  size).  These  are  grasping  and  cutting  forceps 
bent  at  the  proper  angle,  and  with  beak  of  the  needed  length,  that  the  larynx  may  be  reached 
with  ease. 

of  the  probe  close  to  its  end,  a  small  piece  may  be  cut  out  of  the  rubber 
tube  at  this  point,  which  can  then  be  turned  so  as  to  expose  the  proper 
part.     This  was  shown  under  trachoma  of  the  vocal  cords  (Fig.  110). 

As  soon  as  the  escharotic  has  been  applied,  the  instrument  is  quickly 
withdrawn  without  injury  to  other  tissues.     Various  other  instruments 


472  DISEASES   OF  THE  ZARY&X. 

have  been  devised  for  this  purpose,  the  meet  satisfactory  of  which  are 
those  recommended  by  Sajous,  of  Philadelphia,  and  Jarvis,  of  New  York. 
The  galvano-rautery  is  sometimes  an  excellent  instrument  for  de- 
stroying these  growths.  It  is  important  that  the  electrode  employed 
should  have  a  small  platinum  point  which  will  heat  or  cool  rapidly,  other- 
wise much  damage  may  be  done  to  surrounding  tissues.  This  cautery  is 
more  difficult  to  use  than  chromic  acid,  and  is  usually  less  satisfactory 
in  its  results,  though  in  some  cases  it  is  preferable.  The  most  satisfac- 
tory handle  is  one  in  which  the  circuit  is  closed  by  removing  the  finger 
from  the  button  (Fig.  Ill),  instead  of  one  in  which  the  button  must 
be  pressed,  as  the  former  causes  less  movement  of  the  end  of  the 
electrode.  The  mechanical  treatment  of  these  tumors  is  carried  out 
by  friction,  evulsion,  and  crushing  or  cutting,  which  may  be  performed 
by  various  snares,  ecraseurs,  forceps,  scissors,  or  knives. 


Fig.  16ti.  —  Mackenzie's  Tube  FoRctPS  Q£  ordinary  size). 

As  a  rule,  patients  cannot  be  operated  upon  under  general  anaesthesia 
unless  tracheotomy  has  first  been  performed ;  but  since  the  discovery  of 
the  local  anaesthetic  properties  of  cocaine,  it  is  seldom  necessary  to  do  a 
preliminary  tracheotomy  except  in  young  children. 

Friction —  VbltoZini's  Method. — The  simplest  and  sometimes  the  most 
efficient  measure  for  mechanical  destruction  of  laryngeal  tumors  is  per- 
formed with  a  sponge  firmly  fastened  to  a  staff  preferably  made  of  mal- 
leable steel.  This  is  passed  into  the  larynx,  and,  with  the  finger  and 
thumb  of  the  left  hand  holding  the  organ  as  firmly  as  possible,  it  is 
rubbed  vigorously  up  and  down  for  two  or  three  times  and  then  re- 
moved. The  operation  may  be  repeated  after  a  week  or  ten  days.  In 
case  of  soft  tumors,  it  will  frequently  be  successful.  This  operation  is 
peculiarly  adapted  to  the  laryngeal  growths  of  infants,  which  are  gen- 
erally of  a  papillary  character  and  difficult  to  remove  by  forceps.  In 
these  patients  it  is  more  easily  carried  out  if  tracheotomy  has  first  been 
performed  and  a  general  anaesthetic  given.  The  probang  may  then  be 
carried  into  the  larynx  by  the  aid  of  the  index  finger  of  the  left  hand, 
and  the  treatment  accomplished  without  pain.  As  a  rule,  an  expert 
may  do  this  operation  without  previous  tracheotomy,  but  O'Dwyers  tube 
or  Schrotter's  dilator  should  be  at  hand  for  use  in  case  of  prolonged 
spasm  of  the  glottis. 


BENIGN  TUMORS   OF  THE  LARYNX 


473 


F.  H.  Hooper,  of  Boston,  recommends  operating  on  these  growths  by  forceps 
in  children,  who  are  thoroughly  anaesthetized  by  ether  and  held  by  the  nurse  in  a 
sitting  posture  so  that  the  laryngoscope  may  be  readily  used.  Under  such  cir- 
cumstances, previous  tracheotomy  renders  the  operation  easier,  but  it  is  not  al- 
ways necessary  {International  Clinics,  October,  1891). 


Fig.  167.— Stoere/s  Instruments:  .4,  ficraseur:  B,  C.  (?,  and  H.  gruillotines  of  various  size  and 
form ;  1),  K,  F,  forceps  blades  of  different  kinds. 


Evulsion  is  effected  with  various  forms  of  snares,  forceps,  or  ecra- 
seurs.  The  snare  forceps  of  Jarvis  (Transactions  of  the  American 
Laryngological  Association,  1886)  may  be  useful  for  removing  growths 
below  the  cords  in  some  cases.  Evulsion  is  the  method  most  commonly 
adopted  and  is  most  applicable  to  comparatively  soft  growths. 


474  DISEASES  OF  THE  LAB  YAW. 

Crushing  may  sometimes  be  accomplished  with  stout  forceps,  and 
is  especially  applicable  to  firm  growths  where  undue  force  would  be 
necessary  for  their  evulsion.  Not  infrequently  a  tumor  which  has  been 
firmly  nipped  with  forceps  will  be  found  to  atrophy  and  completely  dis- 
appear within  two  or  three  weeks. 

Catting  operations  are  most  frequently  accomplished  with  cutting  for- 
ceps, snares,  or  ecraseurs,  though  scissors  and  knives  are  sometimes  useful. 
A  guarded  instrument  should  generally  be  selected  for  the  purpose,  and 
none  but  experts  should  use  any  other.  For  the  removal  of  firm  growths 
some  form  of  snare,  guillotine,  or  Mackenzie's  guarded-wheel  ecraseur 
is  peculiarly  serviceable.  It  is  not  well  to  repeat  attempts  at  removal 
of  these  tumors  more  than  three  of  four  times  at  a  sitting,  because  of 
the  danger  of  setting  up  undue  inflammation  or  possibly  cedema. 


fl/bWijlVsYr 


Fig.  168.— Tobold's  Laryngeal  Knives  (\\  size). 

After  the  operation,  it  is  my  custom  to  have  cold  applications  made 
to  the  neck  for  from  twelve  to  twenty- four  hours,  and  subsequently  to 
apply  to  the  larynx  once  a  day,  or  less  frequently,  some  mild  astringent 
spray  for  the  purpose  of  reducing  congestion. 

Extra- laryngeal  methods,  either  by  tracheotomy  or  thyrotomy,  are  of 
doubtful  propriety  in  most  cases— excepting  where  a  growth  interferes 
with  respiration  or  deglutition — because  by  these  operations  the  vocal 
function  is  apt  to  be  entirely  destroyed  and  life  is  often  endangered. 

Thyrotomy. — It  is  occasionally,  though  not  often,  necessary  to  do  a 
preliminary  tracheotomy  when  thyrotomy  is  to  be  performed,  but  then 
the  latter  operation  should  be  delayed  for  several  weeks,  and  in  the 
mean  time  the  surgeon  should  attempt  to  remove  the  growth  by  endo- 
laryngeal  means  or  through  the  opening  in  the  trachea.  For  division 
of  the  thyroid  cartilage,  the  patient  should  be  placed  with  the  head 
hanging  over  the  end  of  the  table,  in  the  lap  of  the  surgeon,  who  is 
seated  at  the  end  of  the  table  with  his  back  to  the  window.  The  pri- 
mary incision  is  made  in  the  median  line  from  the  cricoid  cartilage  to 
the  thyroid  notch.  The  thyroid  cartilage  should  then  be  carefully 
divided  with  a  strong  knife  or,  if  ossification  has  taken  place,  with  a 
small  circular  or  convex  saw.  If  possible,  a  small  portion  of  the  upper 
part  of  the  thyroid  cartilage  should  be  left  intact,  in  order  that  the  parts 
may  be  accurately  approximated  afterward,  so  as  to  maintain  the  proper 


BENIGN  TUMORS   OF  THE  LARYNX.  475 

relation  of  the  vocal  cords  to  each  other.  In  order  to  avoid  paroxysms 
of  coughing,  great  care  should  be  exercised  that  the  instrument  does  not 
penetrate  through  the  mucous  membrane  into  the  larynx  before  the  car- 
tilage has  been  thoroughly  divided.  AVhen  the  division  is  complete,  the 
alse  should  be  drawn  apart  by  blunt  pointed  retractors.  If  this  cannot 
be  done,  the  crico-thyroid  membrane  should  be  divided  along  the  lower 
border  of  the  thyroid  cartilage,  on  one  or  both  sides  as  may  be  found  neces- 
sary. The  division  of  this  membrane,  however,  is  quite  apt  to  injure 
subsequent  vocalization,  owing  to  the  direct  continuity  of  the  vocal  cords 
with  it,  as  pointed  out  by  Joseph  Leidy  (Transactions  of  the  American 
Laryngological  Association,  1886).  If  the  opening  still  remains  too  small 
the  thyro-hyoid  membrane  should  be  divided  along  the  upper  border  of 
the  thyroid  cartilage,  but  this  is  not  generally  necessary,  and  should  be 
avoided  if  possible.  When  a  sufficient  opening  has  been  attained,  the 
ahe  are  held  back  with  retractors,  the  cavity  is  carefully  cleansed  of 
blood,  and  under  a  bright  light  the  tumor  is  seized  with  hook  or  forceps 
and  torn  off  or  divided  with  strong  curved  scissors.  After  the  growth 
has  been  removed,  Mackenzie  recommends  that  the  base  be  thoroughly 
cauterized  with  solid  sliver  nitrate,  which,  he  states,  is  less  liable  to 
cause  a  subsequent  laryngitis  than  the  galvano- cautery,  or  other  escha- 
rotic,  and  seems  quite  as  efficacious  on  a  raw  surface  (Diseases  of  the 
Throat  and  Nose).  The  alas  of  the  thyroid  are  then  carefully  ap- 
proximated and  fastened  together  in  their  normal  position  by  two 
silver  sutures,  and  the  e.lges  of  the.  wound  carefully  closed.  If  trache- 
otomy has  been  previously  done,  the  tube  should  be  allowed  to  remain 
until  all  danger  from  laryngitis  has  passed  and  the  surgeon  is  confident 
that  no  other  operation  will  be  needed  for  destruction  of  the  growth. 

Sometimes  the  firmness  of  the  tumor  or  its  extensive  attachments  pre- 
vent perfect  removal,  so  that  the  operation  must  be  abandoned  without 
being  completed;  in  such  instances,  as  much  as  possible  of  the  tumor 
should  be  removed,  and  the  cut  surface  thoroughly  cauterized  with 
silver  nitrate.  Krishaber  (Tait's  Cliniques  de  Laryngotomie,  Paris. 
1869)  says  that  division  of  the  cricoid  cartilage  is  never  necessary  for 
the  removal  of  tumors  above  the  cords,  and  that  those  below  can  be 
easily  removed  through  the  crico-thyroid  membrane  or  the  opening  in 
the  trachea.  The  operation,  though  not  extremely  difficult,  is  attended 
by  some  degree  of  immediate  or  consecutive  danger  to  life  from  primary 
or  secondary  hemorrhage  or  inflammation  of  the  air  passages;  therefore 
it  should  not  be  undertaken  without  due  consideration  of  the  possible 
consequences.  Mackenzie  has  shown  that  in  the  majority  of  cases  the 
voice  is  lost,  and  that  the  tendency  to  recurrence  is  quite  as  great  as 
when  the  growth  has  been  removed  through  the  natural  passages. 

Supra-thyroid  laryxgotomy  is  accomplished  by  a  transverse  in- 
cision through  the  superficial  tissues  and  thyro-hyoid  membrane,  either 
along  the  lower  border  of  the  hyoid  bone  or  the  upper  border  of  the 


476  DISEASES  OF  THE  LARYNX. 

thyroid  cartilage.  It  is  less  dangerous  than  division  of  the  thyroid  car- 
tilage, but  it  is  of  very  little  service,  because  the  growths  which  could 
be  removed  by  this  method  can  usually  be  equally  well  removed  through 
the  mouth. 

Intra-thyroid  laryxgotomy,  that  is,  through  the  crico-thyroid 
membrane,  according  to  Mackenzie,  has  been  strongly  recommended  by 
Paul  Bruns  for  the  extirpation  of  growths  originating  from  the  free 
borders  or  under  surface  of  the  vocal  cords,  or  below  the  glottis,  provided 
previous  endo-laryngeal  operations  have  been  unsuccessful.  Sometimes 
division  of  the  membrane  alone  is  sufficient,  but  large  or  sessile  tumors 
may  require  division  of  the  cricoid  cartilage  or  of  some  rings  of  the  tra- 
chea also.  The  operation  is  done  in  the  manner  recommended  for  crico- 
thyroid laryngotomy,  but  all  soft  tissues  are  carefully  dissected  out  from 
the  crico-thyroid  opening,  so  that  only  its  cartilaginous  borders  remain. 
A  canula  is  then  inserted  and  allowed  to  remain  for  several  days  until 
acute  inflammation  has  subsided;  it  is  then  removed,  the  head  is  thrown 
back  so  as  to  make  the  opening  as  large  as  possible,  the  growth  located  by 
an  infra-glottic  mirror,  which  is  then  removed,  and  the  tumor  is  torn  off 
by  short  forceps.  When  the  crico-thyroid  opening  is  too  small,  trache- 
otomy should  be  performed  in  the  first  instance.  After  the  inflamma- 
tion has  subsided,  the  edges  of  the  wound  should  be  drawn  back  and  the 
attempt  made  to  remove  the  tumor.  The  patient  should  wear  the 
canula  for  a  few  months  afterward,  until  the  surgeon  is  convinced  that 
recurrence  will  not  take  place. 

MALIGNANT    TUMORS    OF   THE    LARYNX 

The  term  cancer  of  the  larynx  embraces  a  variety  of  tumors  of  which 
epithelioma  is  by  far  the  most  frequent,  and  sarcoma  next.  Fauvel, 
Cohen,  Bosworth  and  Gottstein  also  recognize  medullary  or  encephaloid, 
and  scirrhous,  as  possible  varieties  of  cancer  in  this  locality.  Such 
growths  give  rise  to  hoarseness,  dyspnoea,  pain,  sometimes  dysphagia,  and 
finally,  in  most  cases,  to  that  peculiar  cachexia  which  generally  attends 
malignant  tumors. 

Anatomical  and  Pathological  Characteristics. — The  growth 
of  these  tumors  is  first  manifested  by  localized  hyperemia,  with  thick- 
ening of  the  parts  which  gradually  increases,  progressively  involving  all 
the  subjacent  tissues  in  the  cancerous  process.  By  a  process  of  cell  pro- 
liferation a  large  irregular  tumor  is  formed  intimately  blended  with  the 
surrounding  structures  and  early  undergoing  ulceration,  which  ultimately 
causes  deep  and  widespread  destruction  of  the  parts.  The  microscopi- 
cal appearances  of  these  growths,  and  their  causes,  are  similar  to  those  of 
like  growths  in  other  localities. 

Symptomatology. — The  symptoms  vary  with  the  size,  location,  and 
condition  of  the  growth.      Pain,  usually  lancinating  in  character,  is  com- 


MALIGNANT  TUMORS  OF  THE  LARYNX. 


477 


tnonly  present.  This,  at  first,  is  generally  confined  to  the  larynx,  and  is 
not  particularly  severe,  but  after  ulceration  occurs,  it  becomes  intense  and 
frequently  radiates  to  the  ears  and  occasionally  to  the  submaxillary  and 
cervical  glands.  Mackenzie  states  that  early  external  evidences  of  laryn- 
geal cancer  are  seldom  present  (Diseases  of  the  Throat  and  Nose). 


Fig.  169.— Cancer  of  Larynx.    Subglottic. 


Fig.  170.— Cancer  of  Larynx. 
Ary-epiglottie  fold. 


In  most  cases  after  the  disease  has  progressed  for  a  few  months  the 
submaxillary  or  cervical  glands,  especially  those  near  the  cornua  of  the 
hyoid  bone,  will  be  found  affected,  and  undue  prominence  of  the  thyroid 
cartilage  may  be  seen  or  felt.  In  rare  cases  ulceration  extends  to  the 
surface.  Hoarseness  is  an  early  symptom,  but  the  voice  is  seldom  en- 
tirely lost.  Dyspnoea  on  exertion  is  frequently  an  early  occurrence; 
and  later  may  be  constant  or  subject  to  severe  paroxysms.  When  ulcera- 
tion has  taken  place,  usually  the  breath  has  a  peculiar  fetor  which  is 


Fig.  171.— Cancer  of  Larynx. 
and  Arytenoid. 


Epiglottis 


Fig.  172.— Cancer  of  Larynx. 
Arytenoid. 


almost  diagnostic.  Sensations  as  of  a  foreign  body  in  the  throat  cause 
frequent  efforts  for  its  expulsion,  but  cough  is  not  a  prominent  symp- 
tom. The  amount  of  secretion  from  the  ulcers  themselves  is  not  very 
large,  but  there  is  profuse  salivation  which  causes  the  patient  great  in- 
convenience or  distress.  The  sputum  consists  of  muco-pus,  frequently 
tinged  with  blood;  sometimes  there  is  profuse  hemorrhage.  Dysphagia 
often  attended  by  some  pain  is  an  early  symptom  with  pharyngo- 
laryngeal  epithelioma.  When  the  disease  is  confined  to  the  interior  of 
the  larynx,  this  symptom  is  not  experienced  so  early,  but  later  it  is 
always  present. 

Upon  inspection  the  neoplasm  appears  at  first  as  a  circumscribed 


478 


DISEASES  OF  THE  LARYNX. 


area   of   congestion  and  submucous  thickening,  the  borders  of  which 
are  not  well  defined.     Usually  it  is  located  upon  one  of  the  ventricular 
bands;  but  occasionally  the  vocal  cords,  epiglottis,  or  ary-epiglottic  folds 
are  first  affected.     In  color  the  growths  vary  from  light  red  to  scarlet 
Epitheliomata  usually  have  the  deeper  hue.     The  most  characteristic 


Fig.  173.— Cancer  of  Larynx. 
Supra-glottic. 


Fig.  174. —Canter  op  Larynx. 
Ventricular  Bands. 


feature  of  malignant  tumors  in  the  larynx  is  the  great  deformity  which 
attends  their  progress.  As  the  process  of  proliferation  and  infiltration 
of  the  surrounding  tissues  advances,  the  growth  which  at  first  appeared 
as  a  limited  area  of  submucous  thickening  without  well  defined  borders 
presents  a  raised  and  irregularly  nodular  surface.  These  tumors  may 
be  single  or  multiple,  and  usually  attain  a  large  size-two  or  more 
centimetres  in  diameter.  Laryngeal  sarcomata  are  soft,  light  in  color 
bleed  easily,  and   ulcerate  early.     In  epithelioma  this  process  may  be 


Fig.  175. 

1-  ig.  1«G. 

Fig.  175—Mixed  Sarcoma.  This  tumor  was  found  in  a  man  about  fifty  years  of  ae-e  who  h»r< 
been  troub.ed  with  dysphonia  for  about  two  years,  and  with  some  dyspncel'for  a  ew  months  S 
growth  was  so  firm  as  to  resist  attempts  at  evulsion  or  crushing.  I.  N.  Danforth  made  a  micro 
scop.c  exannnatton  of  some  portions  which  I  removed,  and  pronounced  it  a  mixed  sarcoma 

Fig.  1,6  -Cancer  of  the  Larynx.  Vocal  Cord.  This  growth  was  supposed  to  be  a  slnmfe 
papilloma,  but  a  microscopic  examination  showed  it  to  be  of  a  semi-malignant  ela  acter  Tbout 
r ^ ra^coSr^  ^  "^  «—  *  ^  ™»r  ™  -  ^-epSttic^: 

long  delayed.  In  either  case,  whether  occurring  early  or  late,  the  ul- 
ceration steadily  progresses  without  any  attempt  at  repair.  Where  both 
the  pharynx  and  the  larynx  are  involved,  ulceration  usually  first  occurs 
at  the  free  edge  of  the  epiglottis  or  on  the  glosso-epiglottic  or  ary- 
epiglottic  folds,  and  quickly  extends  to  the  deeper  portions  of  the  larynx. 
The  epiglottis  is  frequently  so  much  swollen  that  the  lower  portions  of 


MALIGNANT  TUMORS   OF  THE  LARYNX.  47  9 

the  larynx  cannot  be  seen,  but  occasionally  it  is  slowly  destroyed  with- 
out much  tumefaction.  Ulceration  usually  commences  at  a  single  point, 
though  sometimes  two  or  more  ulcerated  spots  may  be  seen  in  the  be- 
ginning. "When  the  disease  is  advanced,  a  large  surface  or  the  whole 
mass  of  the  tumor  appears  in  a  state  of  fungous  ulceration,  bathed  in  an 
offensive,  purulent  secretion. 

Diagnosis. — In  the  early  stages  an  accurate  diagnosis  of  cancer  of 
the  larynx  is  often  difficult  and  may  be  impossible,  but  as  the  disease 
progresses  it  can  generally  be  readily  recognized  by  the  experienced 
laryngologist.  Cancer  of  the  larynx  is  to  be  distinguished  from 
syphilis,  chronic  catarrhal  inflammation,  lupus,  tubercular  laryngitis,  and 
benign  growths.  The  essential  points  in  the  diagnosis  are:  the  age 
of  the  patient,  the  pain,  irregular  thickening  with  marked  deformity, 
extensive  ulceration,  glandular  enlargement,  and  the  microscopic  ap- 
pearance. 

Cancer  of  the  larynx  is  distinguished  from  syphilis  by  the  history, 
the  absence  of  cicatricial  tissue,  the  more  or  less  distinct  tumor  instead 
of  simple  thickening,  the  progressive  ulceration  in  spite  of  treatment, 
and,  in  some  cases,  by  the  cancerous  cachexia  and  by  the  effect  of  the 
iodides  on  the  body  weight.  In  tertiary  syphilis  free  administration  of 
the  iodides,  as  a  rule,  is  speedily  followed  by  increase  of  weight,  with 
other  evidences  of  general  improvement;  whereas  in  malignant  disease, 
although  at  first  slight  improvement  may  apparently  follow  the  admin- 
istration of  these  remedies,  it  is  soon  observed  that  the  weight  is  steadily 
diminishing  and  the  strength  failing. 

Great  thickening  seldom,  and  large  ulcerating  tumors  never,  arise 
from  chronic  catarrhal  inflammation  of  the  larynx,  although  occasionally 
considerable  thickening  and  deformity  of  the  parts  is  present;  but  in 
these  instances  the  history  of  long  continued  inflammation  and  absence 
of  the  peculiar  lancinating  pain,  of  deep  ulceration,  or  of  a  malignant 
cachexia  and  of  the  glandular  enlargement  establish  the  diagnosis. 

We  have  in  lupus  a  slowly  progressive  disease  occurring  most  often 
in  young  subjects:  its  development  in  the  larynx  is  preceded  by  its  ap- 
pearance upon  the  face  or  fauces.  It  is  attended  by  little  or  no  pain 
and  comparatively  slight  swelling.  The  ulceration  progresses  but  slowly, 
and  repair  may  follow  at  some  points.  There  is  not  the  cachexia  which 
is  frequently  witnessed  in  the  patients  of  more  advanced  age  suffering 
from  cancer. 

Cancer  of  the  larynx  is  distinguished  from  tubercular  laryngitis  by 
the  history,  the  absence  of  pulmonary  disease  and  severe  cough,  the 
presence  of  an  irregular  tumor  instead  of  the  more  or  less  uniform 
thickening,  and  the  deep  destructive  ulceration,  with  the  peculiar  fetid 
breath.  In  tubeiculosis  when  the  epiglottis  is  involved,  swelling  is  com- 
paratively uniform  over  the  whole  valve,  and  when  the  arytenoids  or 
ary-epiglottic  folds  are  affected  there  is  a  peculiar  pyriform  appearance 


180  DISEASES   OF  THE  LARYNX. 

commonly  on  both  sides,  not  observed  in  cancer.  The  swollen  tissues 
in  tuberculosis,  so  long  as  ulceration  has  not  taken  place,  are  usually 
lighter  in  color  and  less  dense  than  in  the  malignant  tumor.  The  sar- 
comata have  an  irregular  surface  and  the  appearance  of  an  abnormal 
growth,  quite  distinct  from  the  more  or  less  uniform  swelling  of  tuber- 
culosis. When  ulceration  takes  place  in  tuberculosis,  it  is  usually  super- 
ficial, though  sometimes  deep  and  destructive;  but  by  the  time  the  lat- 
ter occurs,  the  hectic  and  cough,  the  cachexia  and  pulmonary  signs,  will 
at  once  indicate  the  nature  of  the  disease. 

In  the  early  stage  or  until  ulceration  occurs,  it  is  often  very  difficult 
to  distinguish  malignant  growths  from  benign  tumors.  During  the 
course  of  cancer,  before  ulceration  has  occurred,  the  age  (past  middle 
life),  the  pain,  the  irregularly  defined  tumor  of  a  dirty  gray  or  bright 
red  color,  with  almost  constant  glandular  infiltration  in  pharyngo- 
laryngeal  cancer,  and  the  occasional  occurrence  in  in tra-laryngeal  cancer 
of  glandular  enlargement  farther  down  the  trachea  at  the  root  of  the 
neck,  renders  the  diagnosis  fairly  certain. 

Prognosis. — Cancer  of  the  larynx  sometimes  terminates  fatally 
within  from  three  mouths  to  a  year;  but  the  average  duration  is  about 
eighteen  months.  Epithelioma  is  sure  to  terminate  fatally,  though  life 
in  some  instances  may  be  considerably  prolonged  by  operative  measures. 
Sarcoma  may  probably  be  completely  eradicated  in  some  cases.  Death 
is  finally  caused  by  inanition,  asthenia,  asphyxia,  or  hemorrhage. 

Treatment. — All  medicinal  means  have  proved  inefficient  in  check- 
ing the  onward  progress  of  the  disease.  There  are  certainly  no  specifies, 
and  all  drugs  fail  in  the  end ;  even  those  which  are  held  in  most  es- 
teem, such  as  arsenious  acid,  calcium  sulphide,  iodoform,  carbolic  acid, 
ergot,  mercury,  and  turpentine.  As  a  palliative  remedy  to  relieve  pain, 
opium  in  some  form,  and  belladonna  or  cocaine  are  of  importance. 
Morphine,  tannic,  acid,  and  carbolic  acid  locally  (Form.  139,  148)  ren- 
der the  ulcer  less  painful  and  offensive.  Continuous  heat  is  especially 
valuable  in  relieving  the  severe  earache  which  often  attends  this  disease. 
Anti-syphilitic  remedies  should  be  thoroughly  tried  in  all  cases  where 
there  is  any  doubt  as  to  the  diagnosis,  and  sometimes  they  apparently 
check  the  progress  of  the  disease  for  a  short  time.  Surgical  measures 
should  be  adopted  in  all  suitable  cases.  These  are :  endo-laryngeal  at- 
tempts at  removal;  endo-laryngeal  cauterizations;  tracheotomy;  resec- 
tion of  the  larynx:  extirpation  of  the  larynx. 

It  frequently  happens  that  the  true  nature  of  the  laryngeal  growth 
cannot  be  determined  at  first,  and  under  such  circumstances  its  re- 
moval by  endo-laryngeal  methods  should  be  attempted  when  there  is 
any  probability  of  success.  In  a  doubtful  case  portions  of  the  tumor 
should  be  subjected  to  microscopic  examination  and  if  cancer  is  demon- 
strated, all  endo-laryngeal  operations  not  calculated  to  effect  complete 
eradication  should  be  discontinued,  except  in  extreme  cases  where  re- 


MALIGNANT  TUMORS  OF  THE  LARYNX.  481 

moval  of  portions  of  the  growth  will  prevent  suffocation.  In  cancer, 
partial  operations  hpon  the  tumor  usually  accelerate  its  growth. 

Lennox  Browne  ("  Diseases  of  the  Throat,"  second  edition)  recom- 
mends endo-laryngeal  cauterizations  in  certain  cases  confined  to  the  epi- 
glottis, and  not  susceptible  of  removal.  However,  he  justly  remarks  that 
he  fears  the  benefit  of  such  measures  is  but  temporary.  Though  I  have 
never  practised  cauterization  of  laryngeal  cancers,  my  experience  with 
it  in  cancerous  growths  of  the  nasal  passages  leads  to  the  belief  that  in 
this  affection,  as  a  rule,  it  would  be  j)roductive  of  more  harm  than  good. 

Tracheotomy  to  prevent  suffocation  is  frequently  necessary,  and  may 
prolong  life  from  three  to  twelve  or  even  eighteen  months.  In  case 
of  myxo-sarcoma,  I  have  known  life  thus  prolonged  for  four  or  five  years. 

Eesection,  or  partial  extirpation  of  the  larynx,  in  suitable  cases, 
has  been  attended  with  very  favorable  results,  where  complete  extirpa- 
tion of  the  disease  is  possible  by  removal  of  the  epiglottis  or  the  lateral 
half  of  the  larynx.  This  operation  is  indicated  in  small  endo-laryngeal 
epitheliomata  confined  to  one  side,  and  in  sarcomata  not  yet  markedlv 
infiltrating.  It  is  useless  when  the  larynx  is  invaded  from  the  pharynx 
and  whenever  the  adjoining  structures  and  cervical  glands  are  involved. 
Immediately  fatal  results  have  followed  this  operation  in  only  a  small 
percentage  of  cases,  and  usually  life  has  been  very  considerably  pro- 
longed; in  a  few  instances  the  disease  seems  to  have  been  completely 
eradicated.  The  following  description  of  the  operation  is  taken  from 
the  report  of  a  case  by  Lennox  Browne  (op.  cit.) : 

The  patient  being  anaesthetized  a  high  tracheotome  was  done,  and  Hahn's 
tampon  canula  introduced  for  twenty  minutes,  which  time  was  allowed  for  the 
compressed  sponge  about  the  canula  to  expand.  A  median  incision  over  the 
thyroid  was  made  from  just  above  the  tracheal  opening  to  the  hyoid  bone.  The 
tissues  were  carefully  divided  down  to  the  thyroid  and  cricoid  cartilage  ;  the  soft 
parts,  with  the  perichondrium,  were  carefully  lifted  with  a  raspatoiy,  the  peri- 
chondrium being  peeled  away  from  the  cartilage,  while  its  relations  to  the  soft 
parts  remained  undisturbed.  The  separation  was  carried  back  as  far  as  the 
median  line  of  the  boundary  between  the  larynx  and  pharynx,  solely  by  the  use 
of  the  one  instrument.  Part  of  the  hyoid  attachment  of  the  thyro-hyoid  muscle 
was  divided,  but  the  horizontal  incision  over  the  hyoid  bone,  as  recommended  by 
Hahn,  was  unnecessary.  The  thyroid  cartilage  was  then  split  in  the  median  line 
by  cutting-forceps.  The  attachments  to  the  pharynx  were  further  separated  by 
the  raspatory,  knife  handle  and  finger  nail,  and  the  thyro-hyoid  membrane  was 
divided  close  to  its  thyroid  attachment,  the  superior  cornu  of  the  thyroid  carti- 
lage cut  off  by  sharp  pliers,  and  the  cricoid  cartilage  severed  with  the  same  instru- 
ment in  the  median  line  in  front  and  behind.  The  divided  half  of  the  larynx  was 
then  separated  from  the  first  ring  of  the  trachea  and  removed  entire.  There  was 
but  little  hemorrhage,  and  only  two  small  blood  vessels  required  torsion,  the 
comparative  freedom  from  hemorrhage  being  due  to  the  use  of  the  raspatory  in 
keeping  close  to  the  cartilage. 

Laryngectomy,  or  extirpation  of  the  larynx,  has  been  recommended 
and  practised  in  many  instances,  yet  with  but  few  successes.     Since  the 
31 


482  DISEASE*   OF  THE  LARYNX. 

operation    involves    great  danger,  and  the  patient's  subsequent  condi- 
tion is  most  wretched,  it  should  not  be  advised,  unless  we  are  confident 
that  the  disease  is  wholly  confined  to  the  larynx,  and  then  only  after 
the  patient  has  been  fully  apprised  of  the  danger  and  probable  results. 
The  operation  is  described  by  Mackenzie  as  follows : 

A  vertical  incision  should  be  made  from  the  hyoid  bone  to  the  second  ring  of 
the  trachea,  and  the  front  and  sides  of  the  larynx  should  be  thoroughly  freed 
and  exposed  by  careful  dissection,  partly  with  the  cutting  blade  of  the  scalpel, 
but  as  far  as  possible  with  its  handle.  Should  there  be  any  decided  arterial 
hemorrhage,  the  necessary  ligatures  must  be  applied.  The  trachea  should  be 
drawn  forward  with  a  hook,  and  cut  across,  care  being  taken  to  avoid  penetrat- 
ing the  oesophagus.  A  siphon  tube  of  vulcanite  is  then  to  be  inserted  into  the 
windpipe.  In  order  that  the  siphon  may  fit  accurately,  it  is  well  to  have  at  hand 
several  tubes  of  different  sizes.  The  upper  and  posterior  attachments  of  the  lar- 
ynx should  next  be  cut  through,  but  in  dissecting  out  the  cricoid  cartilage  the 
risk  of  button-holing  the  gullet  must  be  avoided  by  keeping  the  knife  close  to 
the  cartilage  ("  Diseases  of  the  Throat  "). 

Sometimes  the  whole  larynx  must  be  removed,  but  not  infrequently 
the  superior  cornua  of  the  thyroid  cartilage  may  be  left.  Hemorrhage 
may  be  stopped  by  ligature  or  torsion,  or  by  some  styptic  solution. 
When  the  surfaces  have  healed  and  the  gap  in  the  throat  has  partially 
contracted,  Gussenbauer's  artificial  larynx  may  be  used.  Though  from 
the  description  the  operation  seems  very  simple,  the  disease  will  often 
be  found  more  extensive  than  anticipated,  making  the  procedure  most 
formidable.  J.  Solis  Cohen  has  recommended  a  modified  form  of  laryn- 
gectomy (Transactions  of  the  American  Laryngological  Association, 
1887),  which  appears  to  offer  many  advantages  over  the  ordinary  opera- 
tion, when  the  disease  is  not  extensive.  As  claimed,  the  wound  is  small, 
the  operation  may  be  done  rapidly  and  with  comparative  safety  to  the 
patient,  the  attachments  of  many  of  the  ligaments  and  muscles  are 
preserved,  important  functional  structures  retained,  and  a  firm  natural 
support  is  left  for  an  artificial  larynx.  His  description  of  the  opera- 
tion is  as  follows: 

1st.  Make  an  incision  from  the  hyoid  bone  to  the  lower  border  of  the  cricoid 
cartilage  and  exactly  in  the  median  line.  2d.  Carefully  separate  the  sterno-hyoid 
muscles.  3d.  Hold  the  soft  parts  aside  and  insert  from  above  one  blade  of  a 
strong  cutting  foiveps,  with  narrow  blades,  beneath  one  wing  of  the  thyroid  car- 
tilage, one-fourth  inch  from  the  angle  of  junction  with  its  fellow,  and  sever  the 
cartilage  vertically  its  entire  length  to  the  crieo-thyroid  membrane.  4th.  Make 
a  similar  cut  on  the  opposite  side.  5th.  Seize  the  freed  angular  portion  of  the 
thyroid  cartilage  comprising  its  entire  respiratory  contingent  with  a  vulcellum 
forceps  and  draw  it  to  either  side,  the  soft  parts  being  separated  meanwhile, 
from  the  inner  surfaces  of  the  attached  wings  of  the  thyroid  cartilages,  with  the 
handle  of  the  scalpel.  6th.  Make  a  transverse  cut  to  sever  the  cricoid  cartilage 
from  the  trachea.  At  this  step  in  the  living  subject,  a  sterilized  cotton  plug 
should  be  inserted  into  the  upper  end  of  the  trachea,  preliminary  tracheotomy 


TRACHEAL  TUMORS.  483 

having  been  performed  previously.  (If  the  cricoid  cartilage  is  to  be  retained,  dis- 
articulate the  arytenoids  and  then  sever  the  soft  parts  above  the  cricoid  instead 
of  below.  This  modifies  the  next  step  in  the  procedure  accordingly.)  7th.  Lift 
the  cricoid  cartilage  forward,  and  carefully  separate  it  with  the  edge  of  the  knife 
from  the  inferior  cornua  of  the  thyroid  laterally  and  superiorly,  the  nfrom  the 
oesophagus  posteriorly.  8th.  Insert  a  finger  into  the  pharynx  from  below  and 
carry  its  tip  over  the  epiglottis  to  draw  that  structure  down.  9th.  Divide  the 
thyro-hyoid  membrane  and  the  fibrous  tissues  still  holding.  10th.  Lift  out  the 
exsected  respiratory  portion  of  the  larynx.  The  arteries  likely  to  require  ligation 
will  comprise  small  branches  of  the  superior,  middle,  and  inferior  laryngeals. 

The  operation  should  be  strictly  aseptic,  and  where  practicable  should 
liave  been  preceded  several  days  by  a  preliminary  tracheotomy.  George 
E.  Fowler  has  adopted  this  operation  once  for  the  removal  of  an  epithe- 
liomatous  larynx,  with  most  satisfactory  results  {American  Journal, 
of  Medical  Sciences,  October,  1890).  Gussenbauer's  artificial  larynx  was 
placed  in  position  on  the  forty-first  day,  and  on  the  seventy-third 
day  after  the  operation  the  patient  was  discharged,  and  was  able  to 
speak  in  a  loud  whisper  without  the  aid  of  the  artificial  larynx.  Sev- 
eral months  later  there  was  no  evidence  of  recurrence,  and  the  patient 
remained  in  good  health. 


EVERSION   OF   THE   VENTRICLE   OF   MORGAGNI. 

The  eversion  of  the  ventricle  of  Morgagni  is  a  very  rare  occurrence. 
I  am  not  aware  that  more  than  three  cases  are  on  record.  One  of  these 
was  diagnosticated  before  death  by  George  M.  Lefferts  {Neio  York  Medi- 
cal Record,  June,  1876),  but  the  others  were  not  detected  until  the 
autopsy;  therefore  we  are  unable  to  give  any  distinctive  signs.  The 
condition  is  likely  to  be  mistaken  for  a  morbid  growth.  In  the  case 
reported  by  Lefferts  thyrotomy  was  performed,  and  the  everted  saccu- 
lus  cut  off  with  scissors. 


TRACHEAL  TUMORS. 

Laryngeal  and  tracheal  diseases,  as  already  noted,  are  so  nearly  re- 
lated that  it  is  most  convenient  to  consider  them  in  close  connection. 
Tumors  in  the  trachea  are  extremely  uncommon.  Those  at  its  upper 
extremity  may  generally  be  seen  by  laryngoscopic  examination,  but  it 
may  be  difficult  to  determine  whether  they  are  located  below  the  cricoid 
cartilage  or  in  the  lower  part  of  the  larynx.  Great  care  must  always  be 
observed  in  the  diagnosis  of  disease  in  the  trachea,  otherwise  we  are  apt 
to  be  misled  by  imperfect  reflection  of  the  light.  Poor  illumination 
may  apparently  reveal  objects  which  do  not  exist.  I  have  seen  but 
three  cases  of  tracheal  tumor:  one  a  large  growth,  as  represented  in  the 
cut,  and  two  others,  papillary  growths,  upon  the  anterior  wall  of  the 


4*4  DISEASES  OF  THE  LARYNX. 

trachea  about  two  inches  below  the  glottis.  Tumors  in  this  situation 
may  be  either  benign  or  malignant. 

Etiology. — The  causes  are  similar  to  those  of  corresponding  tumors 
in  the  larynx. 

Symptomatology. — These  neoplasms  when  small  cause  no  distinc- 
tive symptoms,  but  as  they  increase  in  size  dyspnoea  results  and  there  is 
usually  considerable  cough  and  some  expectoration.  Upon  inspection 
the  growth  usually  presents  a  cauliflower  or  papillary  appearance,  some- 
times congested,  occasionally  semi-transparent.  It  is  usually  sessile, 
but  it  may  be  pedunculated. 

Diagnosis. — A  diagnosis  can  only  be  made  by  laryngoscopic  ex- 
amination, and  the  exclusion  of  tracheal  involution  and  syphilitic 
strictures. 

Prognosis. — The  duration  varies  greatly  according  to  the  nature  of 
the  tumor,  but  the  affection  is  ultimately  fatal  in  the  majority  of  cases. 


Fig.  177. — Tumor  in  Upper  Part  of  Trachea.  This  tumor  occurred  in  a  patient  about  sixty 
years  of  age,  but  owing  to  the  large  size  of  his  trachea  it  gave  him  very  little  inconvenience,  and 
therefore  he  declined  to  have  any  attempt  made  for  its  removal.  The  symptoms  in  the  case  were 
hoarseness  and  moderate  dyspnoea. 


Sometimes  the  growth  maybe  removed,  but  usually  it  is  so  deeply  seated 
that  it  is  reached  with  difficulty  and  the  patient  eventually  dies  of 
suffocation. 

Treatment. — When  practicable,  the  tumor  should  be  removed 
through  the  mouth  by  means  of  forceps  or  the  snare,  or  destroyed  with 
chromic  acid.  In  either  case  the  parts  should  first  be  thoroughly  anaes- 
thetized by  cocaine,  and  the  operation  performed  with  great  care  and 
precision.  It  is  quite  possible  that  some  cases  may  be  relieved  by  the 
introduction  of  an  O'Dwyer  tube,  which  by  continuous  pressure  may 
cause  absorption  of  the  growth;  but  if  the  tumor  cannot  be  reached  by 
any  of  these  methods,  and  respiration  is  seriously  obstructed,  trache- 
otomy should  be  performed,  and  if  possible  the  growth  removed  by 
the  cutting- forceps.  Otherwise  a  long,  flexible  tracheal  tube  should  be 
introduced  and  allowed  to  remain. 

Malignant  tumors  in  the  trachea  are  necessarily  fatal,  and  no  form  of 
treatment  will  be  found  of  value,  excepting  palliative  measures  some- 
times of  a  general,  and  sometimes  of  a  local  nature. 


INVOLUTION  OF  THE  TRACHEA.  485 

POST-TRACHEOTOMY  VEGETATIONS. 

After  tracheotomy,  especially  where  the  tube  has  been  worn  for  more 
than  two  or  three  weeks,  not  infrequently  granulations  spring  up  about 
the  point  of  incision  in  the  trachea,  which  more  or  less  occlude  its  cali- 
bre, and,  when  the  canula  is  removed,  interfere  with  respiration.  In 
some  instances  true  papillary  growths  are  developed. 

Etiology. — These  vegetations  are  apparently  due  to  irritation  caused 
by  the  tracheal  canula,  especially  where  one  with  a  fenestra  has  been  used. 

Symptomatology. — While  the  tracheal  tube  remains  in  place,  no 
difficulty  is  experienced;  but  on  its  removal,  respiration  is  impeded,  or 
may  be  completely  obstructed,  by  the  abnormal  growth. 

Diagnosis. — The  symptoms  already  named  will  immediately  sug- 
gest the  nature  of  the  affection,  but  an  accurate  diagnosis  must  rest 
upon  the  exclusion  of  stenosis  by  a  careful  inspection  of  the  tracheal 
wound  and  of  the  larynx.     It  will  be  necessary  in  some  instances  to 


Fig.  178. — Lngals'  Punch  Forceps  (3^  size).    They  were  devised  to  remove  granulations  in  the 
trachea,  but  are  also  serviceable  for  certain  cutting  operations  on  the  nose  or  throat. 

pass  a  Schrotter  dilator  through  the  larynx  to  crowd  the  vegetation 
downward  before  it  can  be  seen  at  the  opening  in  the  trachea. 

Prognosis. — The  cases  are  usually  very  difficult  to  remedy,  and  in 
a  few  instances  it  has  been  impossible  to  remove  the  tracheal  canula. 

Treatment. — Under  general  anaesthesia,  the  granulations  should  be 
removed  by  forceps,  and  their  bases  cauterized  by  silver  nitrate ;  or  they 
may  be  destroyed  by  chromic  acid  or  the  galvano-cautery.  It  is  some- 
times very  difficult  to  grasp  these  with  ordinary  forceps,  and  in  such 
instances  a  pair  of  punch  forceps  (Pig.  178)  which  I  have  had  made 
specially  for  these  cases  will  be  found  very  serviceable.  Sometimes  it 
will  be  necessary  to  crowd  the  growth  down,  with  Schrotter's  dilator  or 
some  similar  instrument  introduced  through  the  larynx,  before  it  can  be 
reached  at  the  tracheal  wound.  Two  or  three  such  cases  have  been 
cured  by  wearing  for  a  short  time  an  O'Dwyer  tube;  but  it  is  not  wise 
to  allow  the  tracheal  wound  to  heal  until  we  are  certain  that  the  vege- 
tations have  been  completely  removed.  In  some  instances  the  laryngo- 
tracheal tube  shown  in  the  article  on  stenosis  of  the  larynx  (Fig.  148) 
will  be  found  necessary. 

INVOLUTION  OP  THE  TRACHEA. 

Involution  of  the  trachea  consists  of  bulging  inward  of  its  walls  re- 
sulting from  external  pressure.  It  is  characterized  by  dyspnoea  pro- 
portionate to  the  obstruction  of  the  tube. 


4si;  DISEASES  OF  THE  LARYNX. 

Etiology. — It  may  be  due  to  pressure  upon  the  trachea  by  an  en- 
larged thyroid  gland,  or  aneurismal  tumor,  or  by  substernal  syphilitic 
growths,  and  rarely  by  disease  of  the  cervical  glands. 

Symptomatology. — The  chief  symptom  is  dyspnoea,  increased  by 
exertion,  and  sometimes  occurring  in  severe  paroxysms  dependent  upon 
swelling  of  the  mucous  membrane  or  partial  closure  of  the  opening  by 
tenacious  mucus. 

Diagnosis. — The  affection  is  to  be  distinguished  from  asthma  or 
any  disease  causing  obstruction  of  the  glottis.  It  can  only  be  diagnos- 
ticated by  exclusion  after  a  careful  laryngoscopic  examination  and  con- 
sideration of  the  history,  physical  signs,  and  symptoms.  For  this  in- 
spection, a  bright  light  must  be  carefully  focused  upon  the  parts  to  be 
examined.  Unless  one  is  thoroughly  familiar  with  the  appearance 
of  the  region,  it  is  easy  to  make  an  error  on  account  of  the  peculiar  re- 
flection of  the  light. 

Prognosis. — The  prognosis  depends  upon  the  amount  of  obstruction 
and  the  nature  of  the  growth  causing  the  pressure,  but  sooner  or  later 
most  cases  prove  fatal. 

Treatment. — If  practicable,  the  cause  of  the  pressure  should  be  re- 
moved; if  not,  tracheotomy  aud  the  employment  of  Kdnig's  long,  fle? 
ible  canula  (Max  Schiiller,  "  Tracheotomie,"  u.  s.  w.,  Deutsche  Chirurgie, 
L880)  will  afford  the  most  relief. 

TRACHEOCELE. 

Tracheocele  consists  of  a  hernial  protrusion  of  the  mucous  mem- 
brane of  the  trachea  between  its  cartilaginous  rings.  Several  cases 
have  been  reported  by  Larry  under  the  title  of  Aerial  Goitre. 

Anatomical  and  Pathological  Characteristics. — The  sac  is 
generally  lined  with  mucous  membrane  and  contains  some  muco-puru- 
leut  secretion.  The  walls  of  the  sac  vary  according  as  it  remains  under 
the  muscles  or  becomes  subcutaneous. 

Etiology. — The  origin  of  the  disease  is  usually  obscure,  though  in 
most  instances  it  apparently  results  from  accidental  straining.  Macken- 
zie cites  two  congenital  cases  (Diseases  of  the  Throat  and  Nose). 

Symptomatology'. — The  voice  may  be  weak  and  there  is  occasional 
dvspncea.  During  ordinary  respiration  there  may  be  but  slight  fulness 
in  the  front  of  the  neck;  but  on  forced  expiration  with  the  mouth  and 
nose  closed,  or  during  cough,  a  tense,  circumscribed  swelling  appears 
upon  the  front  of  the  neck,  the  position  corresponding  nearly  to  that 
of  the  thyroid  gland — sometimes  median,  sometimes  upon  one  or  the 
other  side,  occasionally  bilateral.  By  pressure  while  the  patient  stops 
breathing  or  during  inspiration,  the  tumor  can  usually  be  made  to  dis- 
appear almost  entirely,  although  the  thickened  sac  can  ordinarily  be 
felt  under  the  skin. 


SYPHILIS  OF  THE  TRACHEA.  4S7 

Diagnosis. — The  diagnosis  is  made  by  causing  the  patient  to  expire 
forcibly  with. nose  and  mouth  closed,  or  to  cough,  which  will  make  the 
tumor  distinct ;  then  by  pressure  during  inspiration  it  may  be  reduced. 
The  varying  size  of  the  tumor,  its  increase  on  obstructed  expiration, 
the  impulse  during  cough  conveyed  on  palpation,  together  with  the 
other  signs  just  mentioned,  render  the  diagnosis  certain. 

Prognosis. — When  congenital,  the  affection  will  usually  last  a  life- 
time; but  when  due  to  accident,  it  may  disappear  spontaneously,  or,  if 
not,  it  can  usually  be  cured  by  an  appropriate  appliance.  It  is  not  dan- 
gerous to  life. 

Treatment. — Some  mechanical  appliance  to  prevent  undue  disten- 
tion of  the  sac  is  indicated  and  thus  its  enlargement  may  be  retarded. 
Surgical  interference  has  not  proved  advisable  in  the  majority  of  cases. 

SYPHILIS   OF  THE   TRACHEA. 

Various  pathological  changes  are  met  with  in  the  trachea  similar  to 
those  found  in  the  secondary  and  tertiary  stages  of  syphilis  affecting 
mucous  membranes  elsewhere,  but  they  are  comparatively  rare, 


Fig.  179.— Tracheal  Pustule.  Specific. 

Anatomical  and  Pathological  Characteristics. — Simple  con- 
gestion or  superficial  ulceration,  projecting  ridges,  small  ulcers,  and  oc- 
casional ulcers  of  a  larger  size  are  observed.  In  the  tertiary  stage,  gum- 
matous deposits  in  the  submucous  tissue  seem  usually  to  constitute  the 
first  change.  These  soften,  leaving  ulcers  that  on  healing  result  in  dense 
cicatricial  tissue,  accompanied  by  contraction  and  stenosis.  Dilatation 
may  occur  above  and  below  the  stricture  so  formed.  These  changes 
usually  extend  over  a  large  superficial  area,  and  through  the  whole 
thickness  of  the  tracheal  wall;  even  the  tissues  surrounding  it  may  be 
involved.  Most  frequently  the  lower  portion  of  the  trachea  is  the  seat  of 
the  disease.  The  tube  itself  is  sometimes  shortened,  according  to 
Mackenzie,  but  stricture  is  the  most  common  condition. 

Etiology. — The  localized  phenomena  mentioned  may  be  the  result 
either  of  congenital  or  acquired  syphilis. 

Symptomatology. — Tickling  sensations  in  the  trachea,  a  disposition 
to  cough,  and  occasional  expectoration  of  mucus  or  muco-pus,  with  more 
or  less  alteration  of  the  voice  in  consequence  of  congestion  of  the  cords 


488  DISEASES  OF  THE  LARYNX. 

or  the  collection  of  mucus  upon  them,  and  other  symptoms  of  catarrhal 
tracheitis  are  the  common  symptoms,  except  where  there  is  obstruction 
from  growths  or  from  stricture.  Condylomata  of  considerable  size  or 
marked  stenosis  of  the  trachea  cause  dyspnoea  proportionate  to  the  ob- 
struction of  the  tube;  this  is  usually  associated  with  cough,  expectoration, 
and  occasionally  with  paroxysms  of  suffocation  due  either  to  acute 
swelling  of  the  parts  or  to  collection  of  tenacious  mucus  at  the  seat  of 
stricture.  When  the  stricture  is  very  close,  so  as  constantly  to  in- 
terfere with  respiration,  marked  constitutional  symptoms  may  result. 
By  inspection  of  the  trachea,  lesions  in  its  upper  part  may  usually  be 
seen,  but  those  farther  down  often  escape  observation,  and  can  only  be 
detected  by  careful  physical  exploration  of  the  neck  and  chest. 

Diagnosis. — The  diagnosis  must  be  based  upon  the  results  of  a  care- 
ful laryngoscopic  examination,  and  the  exclusion  of  diseases  liable  to 
cause  compression  of  the  trachea,  as,  for  example,  substernal  tumors  or 
aneurism. 

Prognosis. — The  probable  duration  of  the  affection  can  never  be 
accurately  estimated,  for  under  appropriate  treatment  some  of  the 
lesions  may  disappear,  and  the  patient  may  remain  well  for  years.  When 
decided  narrowing  of  the  trachea  has  taken  place,  the  result  is  likely  to 
be  fatal  within  a  few  months.  Death  may  occur  from  exhaustion  from 
apncea  due  to  swelling,  or  suddenly  from  impaction  in  the  stricture  of 
tenacious  mucus. 

Treatment. — Constitutional  remedies  are  of  prime  importance. 
Mercurials  or  moderate  doses  of  potassium  or  sodium  iodide  should  be 
tried  thoroughly.  Where  these  fail,  large  doses  of  potassium  or  sodium 
iodide  are  often  necessary.  An  excellent  method  of  administering  them 
is  to  begin  with  a  dose  of  gr.  xx.  three  times  daily,  largely  diluted  with 
water  or  milk ;  increase  the  dose  each  day  steadily  by  five  to  ten  grains, 
until  the  maximum  dose  of  from  3  i.  to  3  ii.  is  reached;  this  maybe  con- 
tinued two  or  three  days,  and  then  decreased  to  twenty  grains.  After 
two  or  three  days,  the  dose  should  be  again  increased  as  before.  Such 
large  doses  are  not  to  be  recommended  except  in  extreme  cases.  Ten, 
fifteen,  or  twenty  grains  three  or  four  times  daily  are  sufficient  for 
most  patients,  but  occasionally  a  case  which  would  improve  promptly 
under  large  doses  steadily  progresses  under  the  smaller  quantity.  In- 
sufflation of  iodol  or  iodoform  into  the  trachea,  daily  or  three  times 
a  week,  will  be  found  beneficial  in  the  hyperfemic  stage  and  when 
ulceration  is  present.  If  the  stricture  is  high,  O'Dwyers  laryngeal  tube 
may  be  employed  to  dilate  it;  but  if  low  in  position,  tracheotomy  must 
be  performed,  and  a  canula  which  will  reach  below  the  obstruction 
must  be  inserted  and  worn.  Konig's  long  flexible  canula  is  especially 
adapted  to  this  purpose. 

f 


CHAPTER   XXVIII. 

DISEASES   OF   THE   LARYNX.— Continued. 
FRACTURE   OF    THE   LARYNX. 

Fracture  of  the  larynx  is  a  comparatively  rare  accident.  Up  to  the 
year  1868  only  fifty-two  cases  had  been  recorded  in  medical  literature. 
In  most  instances  the  thyroid  cartilage  is  the  seat  of  fracture,  the  cri- 
coid being  broken  only  by  unusually  extensive  and  dangerous  injuries. 

Anatomical  and  Pathological  Characteristics. — It  is  probable 
that  ossification  of  the  laryngeal  cartilages  renders  them  more  brittle  and 
liable  to  fracture,  and  that,  as  suggested  by  Panas,  premature  senility, 
a  result  of  chronic  alcoholism,  is  sometimes  a  predisposing  factor  {An- 
nates des  Maladies  de  V Oreille,  March,  1878). 

Etiology. — A  direct  cause  is  usually  a  blow,  fall,  or  compression. 
As  a  result,  extravasation  of  blood,  oedema,  or  displaced  fragments  of  the 
cartilage  may  so  obstruct  the  air  passages  as  seriously  to  impede  respira- 
tion. 

Symptomatology. — The  usual  symptoms  are  cough,  dyspnoea  and 
expectoration  of  mucus  tinged  with  blood,  tenderness  or  actual  pain  in 
the  parts,  and  external  swelling  and  deformity.  Subcutaneous  em- 
physema of  the  neck  is  apt  to  follow  early,  in  some  cases  extending  to 
the  arms  and  trunk,  and  on  manipulation  crepitation  may  be  easily  felt. 

Diagnosis. — The  diagnosis  may  be  made  from  the  history  of  vio- 
lence and  the  symptoms  just  indicated. 

Prognosis. — The  accident  is  always  dangerous,  and  judging  from 
the  monograph  by  Henoque,  fracture  of  the  cricoid  is  nearly  always  fatal 
{Gazette  hebdomadaire,  1808,  No.  3,940);  indeed,  there  are  up  to  the  pres- 
ent time  but  three  or  four  cases  of  recovery  known.  If  tracheotomy 
were  promptly  performed,  probably  the  number  of  recoveries  would  be 
larger.  Unfortunately,  owing  to  the  vital  character  of  the  structures 
involved  in  the  injury,  many  patients  die  in  spite  of  the  operation;  or,  if 
recovery  follows,  they  are  subject  for  the  rest  of  their  days  to  trouble- 
some or  dangerous  deformity  of  the  parts. 

Treatment. — Unless  the  symptoms  are  very  slight,  tracheotomy 
should  be  performed  at  once,  and  even  if  dyspnoea  be  absent  the  opera- 
tion is  advisable,  since  not  infrequently  by  a  slight  movement  the  glottis 
becomes  suddenly  closed  and  suffocation  results.  If  the  cartilages  are 
much  crushed,  it  will  be  best  to  lay  open  the  whole  length  of  the  larynx 


4'. H  i  DISEASES   OF  THE  LARYNX. 

and  endeavor  to  replace  and  fix  the  fragments  in  proper  position. 
Leeches  and  cold  applications  should  be  applied  to  the  neck  to  prevent 
extensive  inflammation.  It  is  probable  that  intubation  of  the  larynx  by 
O'Dwver's  method  would  work  well  in  some  cases. 


DISLOCATION    OF   THE   LARYNX. 

Attention  lias  recently  been  called  to  luxation  of  the  crico-thyroid 
articulation,  by  II.  Braun,  of  Kdnigsberg,  according  to  whom  it  occurs 
unilaterally  upon  either  side,  and  may  take  place  daily  or  at  intervals 
of  weeks  or  months  {Berliner  klinische  Wochenschrift,  October,  1890). 
It  may  occur  during  deep  inspiration,  but  more  commonly  during  the 
act  of  yawning.  Probably  a  loose  capsule  is  the  predisposing  cause, 
and  the  sterno-thyroid  and  crico-thyroid  muscles  are  the  active  agents. 
Intense  pain  and  a  feeling  of  anxiety  are  the  chief  symptoms,  a  slight 
prominence  being  produced  at  the  inner  border  of  the  sterno-cleido- 
mastoid  muscle  on  a  level  with  the  lower  border  of  the  thyroid  car- 
tilage. Reduction  may  be  easily  effected  by  digital  pressure  outward 
and  backward,  or  by  a  few  efforts  at  deglutition. 


FOREIGN   BODIES  IN   THE   LARYNX. 

Foreign  bodies  of  great  variety  from  time  to  time  have  been  found 
in  the  larynx,  generally  entering  from  the  mouth  while  the  patient  is 
coughing  or  laughing  during  mastication,  but  sometimes  they  enter 
from  the  oesophagus  in  consequence  of  sudden  inspiration  during  the 
act  of  vomiting,  and  in  rare  instances,  especially  in  military  service,  they 
penetrate  from  without.  The  objects  most  frequently  found  are  pieces 
of  bread,  meat,  bone,  and  other  substances  taken  into  the  mouth  during 
a  meal.  In  children,  peas,  beans,  coins,  buttons,  and  similar  substances 
which  have  been  put  into  the  mouth  in  play,  or  drawn  in  through  blow- 
guns,  are  most  likely  to  be  found.  Pins,  fruit-seeds,  and  coins  are  some- 
times found  in  adults.  Soldiers  upon  the  march,  in  drinking  dirty  water, 
have  occasionally  taken  in  leeches  which  have  become  lodged  in  the 
larynx.  Artificial  teeth,  or  natural  teeth  which  have  become  loosened, 
have  sometimes  become  lodged  in  the  larynx  during  sleep;  other  sub- 
stances which  were  in  the  mouth  on  going  to  bed  are  apt  to  be  drawn  in 
in  the  same  way. 

Symptomatology. — The  symptoms  vary  greatly  with  the  size,  shape, 
and  position  of  the  object,  and  with  the  irritability  of  the  larynx.  A 
large  body,  or  any  object  which  has  become  impacted  in  the  larynx  in 
such  a  position  as  to  cause  clonic  Gpasms  of  the  glottis,  is  apt  to  cause 
immediate  death;  on  the  other  hand,  small  bodies  may  remain  indefi- 
nitely without  very  much  annoyance. 


FOREIGN  BODIES  IN  THE  LARYNX.  491 

I  once  saw  a  patient  two  years  of  age  who  had  drawn  into  the  laiwnx  half  a 
peanut  kernel,  which  after  remaining' for  two  months  was  coughed  out,  having 
caused  in  the  mean  time  no  symptoms  other  than  cough  and  hoarseness. 

Usually,  even  small  and  smooth  bodies  give  rise  to  much  discom- 
fort and  troublesome  cough,  while  sharp  or  irregular  bodies  excite 
severe  paroxysms  of  cough  and  dyspnoea  due  to  spasm  of  the  glottis, 
and  in  many  cases  produce  hemorrhage.  Sometimes  a  body  which 
causes  little  discomfort  in  the  larynx  at  first,  upon  changing  its  posi- 
tion gives  rise  immediately  to  severe  symptoms.  Even  where  irrita- 
tion is  not  sufficient  to  excite  spasm  of  the  glottis  at  once,  the  inflam- 
mation which  supervenes  within  from  twenty-four  to  thirty-six  hours 
may  cause  extensive  swelling,  with  narrowing  of  the  glottis,  which 
may  be  suddenly  occluded  by  spasm  of  the  laryngeal  muscles.  The 
fright  which  attends  this  accident  often  tends  to  increase  the  dyspnoea. 

Diagnosis. — The  diagnosis  will  depend  upon  the  history  of  the  case, 
the  symptoms  already  mentioned,  and  the  results  of  laryngoscopic  in- 
spection when  this  is  practicable;  but  children,  on  account  of  fright, 
sometimes  will  not  give  an  accurate  history,  and  adults  may  greatly  ex- 
aggerate their  symptoms.  In  the  former,  laryngoscopy  can  seldom  be  ac- 
complished, and  even  in  adults  it  is  often  difficult  because  of  irritability 
caused  by  the  foreign  body,  though  this  may  generally  be  relieved  by 
spraying  the  throat  with  a  solution  of  cocaine. 

Prognosis. — In  many  cases  death  occurs  immediately  from  closure 
of  the  glottis  either  by  the  body  itself  or  by  the  spasm  which  it  excites, 
and  life  is  always  in  danger  so  long  as  the  body  is  in  the  larynx.  Fre- 
quently the  immediate  effects  of  the  accident  pass  off,  but  the  inflam- 
mation which  the  foreign  substance  excites  causes  closure  of  the  glottis 
in  from  twenty-four  to  forty-eight  hours  by  swelling  or  spasm.  Some- 
times the  body  suddenly  changes  its  position  with  a  similar  result,  and 
even  after  its  removal  there  is  still  danger  until  acute  inflammation  has 
subsided. 

Treatment. — A  patient  seen  at  the  time  of  the  accident  should  be 
immediately  placed  with  the  head  at  least  forty-five  degrees  below  the 
body,  and  should  be  slapped  vigorously  upon  the  back  in  the  hope  of 
causing  expulsion  of  the  foreign  body;  but  if  in  this  position  respiration 
ceases,  the  head  should  be  raised  at  once  which  possibly  may  so  change 
the  position  of  the  object  as  to  allow  of  respiration.  If  subsequently 
respiration  should  suddenly  cease  in  consequence  of  change  in  the  posi- 
tion, similar  measures  should  be  adopted.  If  by  these  methods  res- 
piration is  not  re-established,  the  patient  should  be  placed  upon  the 
back,  preferably  with  the  head  lower  than  the  body,  and  artificial  respi- 
ration should  be  kept  up  until  medical  assistance  arrives,  even  if  this  is 
delayed  for  half  an  hour.  In  cases  not  immediately  fatal,  the  physician 
may  try  inversion  of  the  patient  with  vigorous  slapping  upon  the  back 
in  the  hope  of  causing  expulsion  of  the  foreign  body.     If  this  does  not 


492  DISEASES  OF  THE  LARYNX. 

succeed,  unless  suffocation  is  imminent,  a  laryngoscopic  examination 
should  be  made  where  practicable  and  an  effort  made  to  remove  the 
object  with  forceps.  If  all  these  methods  fail,  unless  the  body  is 
very  small  and  the  symptoms  slight,  tracheotomy  should  be  done  as  soon 
as  possible,  and  another  effort  at  removal  made  either  through  the 
tracheal  opening  or  through  the  mouth,  whichever  is  deemed  best  at 
the  time. 

In  cases  of  angular  bodies  firmly  impacted,  it  is  occasionally,  though 
rarely,  necessary  to  lay  open  the  whole  length  of  the  larynx  for  their 
removal.  Sometimes  a  body  which  has  been  firmly  fixed  may  be  re- 
moved by  the  methods  already  suggested  after  the  inflammation  and 
swelling  have  been  reduced  by  external  applications.  Bodies  which 
have  been  impacted  in  one  or  both  ventricles  will  not  infrequently  re- 
quire crushing  before  they  can  be  extracted.  This  has  at  times  been 
accomplished  through  the  natural  passages.  When  tracheotomy  has 
been  done  and  the  foreign  body  extracted,  the  tracheal  tube  should  be 
allowed  to  remain  four  or  five  days  until  swelling  has  subsided;  and  it 
should  not  then  be  taken  out  until  the  physician,  by  corking  the  canula 
for  several  hours,  lias  assured  himself  that  laryngeal  respiration  is  easy. 

FOREIUX  bodies  in  the  trachea. 

Foreign  bodies  enter  the  trachea  quite  as  commonly  as  the  larynx,  for 
the  reason  that  small  substances,  as  a  rule,  immediately  pass  through  the 
glottis.  Isolated  cases  of  this  accident  have  been  recorded  from  a  very 
early  period,  but  the  first  extensive  treatise  upon  the  subject  was  by  Lewis, 
in  1759,  though  the  subject  was  not  treated  exhaustively  until  the  publi- 
cation of  the  late  S.  D.  Gross'  work  on  Foreign  Bodies,  in  1854.  Foreign 
bodies  in  the  trachea  are  due  to  the  same  causes,  and  occur  in  the  same 
way,  as  the  similar  affection  of  the  larynx. 

Symptomatology. — The  symptoms  will  necessarily  vary  with  the 
character  of  the  body  which  has  been  introduced,  as  well  as  with  the 
irritability  of  the  tracheal  mucous  membrane.  Patients  have  occasion- 
ally drawn  foreign  bodies  of  considerable  size  into  the  trachea  without 
causing  any  symptoms  which  would  suggest  to  them  that  such  an  acci- 
dent had  occurred.  Large  bodies  or  fluid  drawn  into  the  trachea  may 
cause  immediate  death,  or  severe  dyspnoea,  which,  growing  gradually 
worse,  induces  pallor  of  the  general  surface  with  lividity  of  the  lips  and 
nails,  cold  sweating,  and  all  of  the  symptoms  of  suffocation,  which  be- 
come more  and  more  pronounced  until  death  supervenes.  Sometimes 
the  symptoms  are  comparatively  slight  at  the  time  of  the  accident,  but 
a  few  hours  later,  owing  to  a  change  in  the  position  of  the  body,  to 
swelling  of  the  mucous  membrane,  or  to  spasm  of  the  glottis,  sudden 
death  may  occur;  or,  the  symptoms  of  suffocation  soon  subsiding,  the 
patient  may  breathe  easily  again  for  a  variable  length  of  time  until  the 


FOREIGN  BODIES  IN  THE  TRACHEA.  493 

"paroxysm  is  renewed,  possibly  with  fatal  effect.  If  the  body  is  small  and 
smooth,  it  may  pass  through  the  trachea  and  drop  into  the  bronchial 
tubes,  and  unless  soon  removed  it  will  ere  long  set  up  inflammation. 
Coins  sometimes  are  lodged  edgewise  in  the  trachea  and  give  rise  to 
little  or  no  discomfort,  but  they  may  suddenly  become  turned  across 
the  tube  and  cause  suffocation.  As  a  rule,  bodies  of  moderate  size  soon 
set  up  irritation  and  inflammation  resulting  in  cough  by  which  the  ob- 
ject may  be  thrown  out  or  become  lodged  in  the  larynx  with  disastrous 
results;  or  the  inflammation  may  finally  extend  to  the  lungs,  causing 
pneumonic  abscesses  or,  eventually,  phthisis.  Rarely,  concretions  form 
about  small  bodies,  greatly  increasing  the  difficulty  which  they  cause. 
Kernels  of  corn,  beans,  and  similar  substances  may  be  greatly  enlarged 
by  swelling,  from  absorption  of  moisture,  and  they  sometimes  germinate. 
In  cases  where  severe  dyspnoea  immediately  follows  the  accident,  but 
suddenly  passes  off  without  expulsion  of  the  body,  we  infer  that  it  was 
first  impacted  in  the  larynx  and  subsequently  drawn  into  the  trachea. 
Frequently  movable  bodies  in  the  trachea  may  be  felt  by  the  patient  as 
they  pass  up  and  down  during  the  acts  of  respiration  or  cough,  and 
these  movements  may  sometimes  be  felt  by  the  finger  over  the  trachea. 
Angular  bodies  cause  more  or  less  pain;  smooth  or  small  bodies  may 
cause  no  sensations  whatever.  Bodies  lodged  in  the  trachea  cause  more 
or  less  diminution  of  the  respiratory  murmur,  or  a  slight  rale  which 
may  be  heard  over  the  entire  chest.  Usually  the  foreign  substance  drops 
into  one  of  the  bronchial  tubes,  about  five  out  of  eight  gravitating  to 
the  right  side;  as  a  result,  there  is  deficient  movement  and  feebleness  of 
the  respiratory  murmur  over  the  corresponding  side.  Sometimes  the 
body,  or  the  mucus  collecting  about  it,  causes  bronchial  rales  heard  on 
one  side  only.  These  signs,  when  found,  are  very  important  from  a  diag- 
nostic point  of  view,  but  are  not  universally  present,  even  though  the 
body  be  lodged  in  the  bronchial  tube,  especially  in  the  case  of  buttons 
or  coins  turned  edgewise. 

A'ocal  fremitus  is  also  diminished  over  the  obstructed  lung,  and  there 
may  be  slight  dulness  on  percussion,  due  to  collapse  of  some  of  the  air 
vesicles  or  to  collection  of  mucus  in  the  bronchial  tubes.  By  laryngo- 
scopy examination  the  foreign  body  can  sometimes  be  detected  in  the 
trachea. 

Diagnosis. — Usually  there  is  a  suggestive  history,  but  it  is  not  al- 
ways possible  to  tell  whether  the  body  has  been  ejected  or  not.  When 
the  foreign  substance  can  be  seen  or  felt  in  the  trachea,  or  when  with  a 
history  of  the  accident  the  difference  of  the  plrysical  signs  upon  the  two 
sides  of  the  chest  indicates  obstruction  of  a  bronchus,  we  may  be  posi- 
tive of  our  diagnosis.  There  are  frequently  cases  where  it  is  impos- 
sible to  diagnosticate  the  presence  of  small  or  smooth  bodies  which 
have  been  drawn  into  the  trachea ;  in  these  we  are  obliged  to  wait  for 
time  to  decide. 


494  ZHHEA8ISS   OF  THE  LARYNX. 

Prognosis. — Where  the  immediate  danger  has  been  survived,  the 
greatest  risk  occurs  between  the  second  day  and  the  end  of  the  first 
month;  during  the  succeeding  month  the  mortality  notably  diminishes, 
but  later  it  again  increases.  As  already  indicated,  the  prognosis  is  al- 
ways serious  so  long  as  the  foreign  body  remains  in  the  air  passages,  the 
gravity  depending  upon  the  size  and  nature  of  the  body,  the  amount  of 
dyspnoea,  and  the  changes  set  up  in  the  lungs.  When  it  is  ejected  or 
removed,  recovery  is  usually  rapid.  Foreign  substances  have  sometimes 
been  coughed  up  weeks,  months,  or  even  years  after  the  accident,  the 
patient  in  the  mean  time  having  suffered  more  or  less  from  the  irritation 
which  they  produced. 

For  the  encouragement  of  those  in  whom  the  body  cannot  be  found,  a  case 
mentioned  by  Gross  may  be  cited,  in  which  a  boy  three  years  old  drew  a  piece  of 
bone  into  tbe  trachea,  which  remained  in  the  lung  and  was  finally  ejected  during 
a  fit  of  coughing  six  years  later.  A  child  was  once  brought  to  me  who  had 
drawn  a  button  into  the  trachea.  I  did  tracheotomy,  but  the  button  could  not 
be  obtained.  The  wound  was  kept  open  for  several  weeks  and  then  allowed  to 
heal,  and  about  a  month  later  the  button  was  expelled  during  a  fit  of  coughing. 

Treatment. — The  indications  are  to  remove  the  body  as  soon  as 
possible.  This  may  sometimes  be  done  by  inverting  the  patient  and 
slapping  him  upon  the  back,  as  recommended  for  foreign  bodies  in  the 
larynx,  or  by  Padley's  method  which  consists  in  placing  a  strong  bench 
with  one  end  upon  a  couch,  with  the  other  upon  the  floor,  and  causing 
the  patient  to  sit  on  the  upper  part  with  his  knees  fixed  over  the  end, 
and  while  taking  a  deep  breath  to  lay  himself  quickly  back  supinely  upon 
the  bench  (London  Lancet,  Vol.  II,  18T8).  The  inspiration  opens  the 
glottis,  and  the  supine  position  favors  the  expulsion  of  the  foreign  body. 
If  it  should  happen  to  lodge  in  the  larynx,  the  patient's  hold  upon  the 
bench  with  his  knees  enables  him  quickly  to  regain  the  upright  position, 
so  that  the  body  will  again  fall  back  into  the  trachea.  Children  may 
be  held  up  by  the  feet,  or  the  child's  body  may  be  allowed  to  hang  from 
the  nurse's  lap,  the  back  being  slapped  in  the  mean  time.  When  at- 
tempting either  of  the  above  methods,  the  surgeon  should  be  ready  to 
perform  tracheotomy  at  once,  for  sometimes  the  body  becomes  firmly  im- 
pacted in  the  glottis  and  suffocation  would  immediately  ensue  unless  the 
windpipe  were  opened.  It  is  needless  to  say  that  the  methods  named  are 
only  likely  to  succeed  where  the  body  is  small  and  smooth,  as  in  the  case 
of  coins,  buttons,  peas,  and  beans,  and  but  recently  inhaled.  The 
methods  just  recommended  may  sometimes  be  tried  with  advantage  after 
tracheotomy  has  been  done,  providing  the  body  cannot  be  found  and  re- 
moved by  forceps.  In  most  cases  tracheotomy  will  be  necessary,  and  the 
surgeon  should  advise  it  at  once  when  he  is  sure  that  a  foreign  body  is  in 
the  trachea,  remembering  that  delay  is  always  dangerous;  yet  he  should 
not  fail  to  inform  the  friends  that  some  patients  recover  without  opera- 


FOREIGN  BODIES  IN  THE  TRACHEA.  495 

tion.  In  children  chloroform  is  usually  preferred  as  an  anaesthetic,  but 
in  adults  local  anaesthesia  may  be  produced  by  cocaine.  Tracheotomy 
having  been  done,  the  foreign  body  will  frequently  be  coughed  out  im- 
mediately, but  if  not,  it  should  be  sought  with  instruments.  For  this 
purpose  Trousseau's  tracheal  forceps  are  well  adapted,  but  I  have  had 
better  results  with  Carl  Seller's  laryngeal  tube  forceps  (Fig.  180),  with 
which  upon  one  occasion  I  was  enabled  to  remove  a  swollen  kernel  of 
corn  that  was  deep  in  the  right  bronchus,  and  on  another,  a  small  spic- 
ula  of  bone  from  deep  in  the  left  bronchus. 

A  peculiar  accident  occurred  a  few  years  ago  to  the  son  of  one  of  our  well 
known  physicians.  The  boy  was  playing  with  a  blow-gun,  in  which  he  had  a 
shawl-pin  used  as  a  dart.  By  a  forcible  inspiration  the  shawl-pin  was  drawn, 
head  foremost,  into  the  trachea,  from  which  it  was  removed  after  tracheotomy 
with  great  difficulty  because  of  its  length  and  its  position  with  the  point  upward. 

If  the  body  cannot  be  found,  it  is  recommended  that  the  edges  of 
the  tracheal  wound  be  stitched  to  the  integument,  or  that  ligatures  be 


Fig.  180.— Seiler's  Tube  Forceps  (2-5  size). 

passed  through  the  trachea  and  fastened  with  an  elastic  behind  the  neck, 
in  order  to  keep  the  wound  open.  This  device  will  answer  very  well 
for  two  or  three  days,  but  it  is  not  applicable  where  the  tracheal  wound 
must  be  kept  open  for  several  weeks ;  in  such  instances  I  would  recom- 
mend that  a  large  tracheal  canula  be  left  in  the  wound,  but  that  it  be 
removed  from  time  to  time  and  efforts  be  made  to  remove  the  foreign 
body  either  by  inversion  or  by  forceps.  After  the  foreign  substance 
has  been  extracted,  the  trachea  should  be  kept  open  for  three  or  four 
days  to  allow  all  inflammation  to  subside,  and  to  be  sure  that  no  other 
particles  remain.  The  canula  may  then  be  removed  and  the  wound 
allowed  to  heal.  When  tracheotomy  has  been  done  within  a  few  hours 
after  the  accident  has  occurred,  and  where  the  body  has  been  easily  re- 
moved, the  tracheal  wound  may  be  allowed  to  close  at  once.  In  the 
event  that  a  foreign  body  becomes  impacted  in  the  bronchi  so  low  that 
it  cannot  be  removed  by  tracheotomy,  the  question  of  bronchotomy 
will  arise;  but  notwithstanding  the  brilliant  results  of  modern  sur- 
gery, experience  up  to  the  present  time  is  against  it,  as  the  danger 
to  life  far  overbalances  the  chances  of  success,  and  there  is  a  possibility 
that  the  object  may  eventually  be  expelled  spontaneously. 


DISEASES    OF   THE   LARYNX. 
SPASM   OF   THE  GLOTTIS. 

Synonyms. — Laryngismus  stridulus;  spasmus  glottidis;  suffocative 
laryngismus;  spasmodic,  cerebral  or  false  croup. 

Spasm  of  the  glottis  is  a  condition  iu  which  there  is  a  temporary, 
complete  or  incomplete,  spasmodic  closure  of  the  glottis  or  vestibule  of 
the  larynx,  preventing  free  inspiration.  It  is  characterized  in  the  former 
case  by  cessation  of  the  respiratory  movements,  and  in  the  latter  by 
stridulous  respiration,  almost  identical  with  that  of  true  croup  or  that 
of  whooping-cough. 

It  is  a  purely  nervous  disease,  and  was  formerly  believed  always  to 
result  from  cerebral  disorders.  It  is  now  known  to  be  due  also  to  direct 
or  reflex  peripheral  irritation  from  a  great  variety  of  causes;  for  exam- 
ple, pressure  on  the  recurrent  laryngeal  nerve,  the  presence  of  irritating 
substances  in  the  alimentary  canal,  or  irritation  of  the  gums  in  denti- 
tion. Lubet-Barbon  {Revue  mensuelU  des  maladies  de  Venfance,  Paris, 
Annual  »f  the  Universal  Medical  Sciences,  L892)  states  that  adenoid  hy- 
pertrophy in  the  uaso-pharynx  is  nearly  always  present.  The  attack  is 
verv  likely  to  occur  during  acute  catarrhal  inflammation  of  the  larynx, 
and  may  be  excited  by  mental  or  physical  irritation  of  the  child.  With 
nursing  babes  it  is  frequently  brought  on  by  the  entrance  into  the  larynx 
of  a  little  milk  and  sometimes  by  dandling  the  child  in  the  arms. 

Symptomatology. — The  great  majority  of  cases  occur  between  the 
a^es  of  four  and  twentv-four  months,  and  verv  few  after  the  latter.  It 
is  most  common  in  boys,  and  more  frecpteut  in  poorly  nourished  chil- 
dren than  in  those  well  cared  for.  The  attack  usually  comes  on  sud- 
denlv  in  the  night,  when  the  child  awakens  in  fright  from  great  dyspnoea 
or  temporary  suspension  of  breathing.  After  a  few  respirations  it  cries 
out,  and  soon  falls  asleep  as  though  nothing  had  occurred.  In  severe 
cases  the  symptoms  are  more  violent:  the  breathing  suddenly  becomes 
difficult,  inspiration  is  prolonged  aud  stridulous,  and  in  a  few  moments 
the  respiratory  movements  cease  in  consequence  of  complete  closure  of 
the  glottis:  the  face,  which  was  flushed,  becomes  pallid,  and  this  is 
sj)eedilv  fullowed  by  lividity:  the  eyes  roll,  the  veins  in  the  neck  become 
turgid :  and  there  are  spasmodic  contractions  of  the  hands  and  feet. 
General  convulsions  sometimes  ensue.  In  mild  cases  the  attack  often 
does  not  recur  until  the  following  night.  The  severer  the  paroxy.-ms. 
the  greater  will  be  the  rapidity  with  which  they  succeed  each  other. 
In  some  severe  cases  they  follow  each  other  in  rapid  succession,  or  there 
may  be  an  almost  endless  spasm  which  does  not  relax  until  life  is  ex- 
tinct. In  the  more  common  form  of  the  affection  the  child  may  appear 
perfectlv  well  the  following  day  and  there  may  be  no  return  of  the 
paroxysm,  but  usually  it  is  repeated  the  next  night  or  even  within  a 
few  hours.  As  a  rule,  there  is  no  fever,  but  profuse  sweating,  especially 
of  the  head,  is  a  common  symptom. 

Diagnosis.— The  disease  is  not  likely  to  be  mistaken  for  any  other 


SPASM  OF  THE  LARYNX  IN  ADULTS.  497 

except  true  croup,  from  which  it  may  be  diagnosticated  by  the  absence 
of  fever  and  the  intermittence  of  symptoms  between  the  paroxysms. 

Peogxosis. — The  attacks  last  but  a  few  minutes,  but  they  may  recur 
after  a  few  hours  or  the  following  night,  or  in  severe  cases  may  be 
speedily  repeated.  In  the  milder  forms,  recovery  is  common,  but  others 
are  often  fatal,  and  sometimes  during  the  first  paroxysm,  which  may  last 
but  one  or  two  minutes.  In  cases  depending  upon  disturbance  of  the 
digestive  organs  or  slight  irritating  causes,  the  prognosis  is  favorable, 
providing  the  paroxysms  do  not  last  too  long  or  follow  each  other 
quickly;  whereas  in  those  resulting  from  cerebral  disease,  or  in  those 
where  the  intervals  between  the  paroxysms  are  short,  the  prognosis  is 
grave.  As  a  rule,  the  greater  the  interval  between  the  paroxysms  and 
the  slighter  th.e  individual  attacks,  the  better  the  chances  of  recovery. 

Tkeatmext. — During  the  paroxysm,  flagellation,  and  the  dashing 
of  cold  water  in  the  face,  are  the  most  common  remedies. 

To  terminate  the  spasm  and  prevent  its  recurrence,  in  the  majority 
of  cases  nothing  is  better  than  v\  xv.  to  xxx.  of  the  compound  syrup 
of  squills,  which  should  be  repeated  every  fifteen  minutes  until  vomit- 
ing occurs.  Tickling  the  fauces  with  a  feather  or  the  finger  is  some- 
times sufficient  to  excite  vomiting,  apomorphine  in  minute  doses  may  be 
injected  subcutaneously,  or  turpeth  mineral  may  be  given  for  the 
same  purpose  in  doses  of  gr.  ss.  to  ij.  or  even  more.  Teaspoonful 
doses  of  powdered  alum  act  promptly  and  efficiently.  To  relieve  the 
paroxysm  a  hot  bath  or  a  sitz  bath  at  95°  F.  may  be  employed,  or  chloro- 
form may  be  carefully  administered.  An  enema  of  tincture  of  assafce- 
tida,  Tit  xx.  to  xxx.,  ad  3  i.  of  warm  gruel  or  milk  is  sometimes  a  most 
useful  remedy  to  prevent  recurrence  of  the  attack.  Tincture  of  castor 
and  musk  are  also  valuable  for  the  same  purpose.  The  cause  of  the 
spasm  must  be  sought  and  removed.  It  is  most  commonly  found  in 
some  derangement  of  the  digestive  organs  associated  with  slight 
catarrhal  laryngitis.  The  spasm  may  be  caused  by  an  enlarged  thy- 
mus gland,  especially  in  young  children.  It  has  been  known  to  arise 
from  irritation  of  the  prepuce.  It  is  not  infrequently  caused  by  hysteria 
or  cerebral  or  cerebro-spinal  disease.  Subsequent  to  the  paroxysm,  vege- 
table tonics,  cod-liver  oil,  and  the  bromides  are  generally  beneficial. 

SPASM  OF  THE  LARYNX  IN  ADULTS. 

Spasm  of  the  larynx  is  much  less  frequent  in  adults  than  false  croup 
in  children,  and  is  most  commonly  observed  in  nervous  women. 

Etiology. — Spasm  of  the  larynx  is  sometimes  a  pure  neurosis,  but 
may  also  be  produced  by  irritation  of  the  larynx  by  foreign  bodies,  or 
by  oedema,  or  by  laryngeal  tumors.  Sometimes  it  results  from  irritation 
of  the  recurrent  laryngeal  nerve,  and  in  some  cases  a  paroxysm  comes 
on  during  sleep,  without  apparent  cause. 


498  DISEASES  OF  THE  LARYNX. 

Symptomatology. — The  paroxysm  comes  on  suddenly.  There  is 
stridulous  inspiration,  speedily  increasing  dyspnoea,  and  in  severe  cases 
temporary  arrest  of  respiration,  which  may  be  followed  by  expectoration 
of  a  considerable  quantity  of  viscid  mucus.  On  inspection  at  the  time, 
the  mucous  membrane  of  the  larynx  is  usually  found  slightly  congested, 
but  it  may  appear  perfectly  healthy,  and  the  vocal  cords  are  seen  to  sepa- 
rate for  an  instant,  and  then  to  suddenly  draw  together. 

Diagnosis. — The  diagnosis  rests  upon  suddenness  of  onset,  the  pe- 
culiar obstruction  of  respiration,  and  the  exclusion  of  foreign  bodies  or 
tumors  by  inspection. 

Prognosis. — The  attacks  are  of  short  duration,  and  are  seldom,  if 
ever,  dangerous  excepting  -when  resulting  from  foreign  bodies. 

Treatment. — Inhalations  of  steam  impregnated  with  soothing  rem- 
edies as  conium,  belladonna,  or  stramonium,  or  inhalations  of  the  smoke 
of  burning  stramonium,  are  useful  in  relieving  the  tendency  to  spasm 
when  the  attacks  are  recurring  with  frequency.  The  inhalation  of  a 
few  whiffs  of  chloroform  will  give  speedy  relief  in  most  cases.  After 
the  attack,  general  and  nerve  tonics  are  indicated.  For  this  purpose  a 
pill  containing  one  grain  each  of  zinc  valerianate,  quinine  valerianate, 
and  iron,  is  an  excellent  combination.  Potassium,  sodium,  or  ammonium 
bromide  may  also  be  administered  to  relieve  the  irritability  of  the  larynx. 
To  prevent  the  spasm  of  the  glottis  which  occurs  in  some  patients  dur- 
ing and  after  applications  to  the  larynx,  the  patient  should  hold  his 
breath  during  the  application  and  for  a  second  or  two  afterward  and 
then  recommence  breathing  slowly,  through  the  nose. 

IRRITATIVE   COUGH. 

A  dry.  hacking,  and  sometimes  paroxysmal  cough  is  apparently  of 
nervous  origin  and  not  infrequently  accompanied  by  hyperemia  of  the 
mucous  membrane.  The  reflex  form  may  be  associated  with  disorders 
of  the  digestive  organs  or  of  the  uterus;  it  is  sometimes  violent  during 
dentition,  and  it  may  also  result  from  varix  or  enlarged  glands  at  the 
base  of  the  tongue,  enlargement  of  the  tonsil,  or  elongation  of  the  uvual. 
The  cough  is  most  frequent  in  the  morning,  and  is  usually  referred  to 
the  region  of  the  trachea. 

Treatment. — Any  of  the  associated  marked  conditions  should  re- 
ceive appropriate  treatment,  and  sedatives  or  antispasmodics  in  the 
form  of  troches  and  sprays  should  be  given  to  check  the  tendency  to 
cough. 

NERVOUS   COUGH. 

By  nervous  cough  we  refer  to  a  peculiar  cough  most  frequently  man- 
ifest in  hysterical  women,  but  sometimes  occurring  in  men.  It  is  usu- 
ally characterized  by  a  resemblance  to  the  cry  of  one  or  other  of  the 


ANAESTHESIA   OF  THE  LARYNX.  499 

lower  animals,  most  frequently  the  yelping  of  a  dog  (Cohen:  "Diseases 
of  the  Throat  and  Nose  ").  It  is  apparently  purely  of  a  neurotic  origin, 
the  most  careful  examination  failing  to  detect  any  definite  lesion. 
No  very  satisfactory  method  of  treatment  can  be  suggested,  though 
electricity  has  sometimes  proven  effectual.  Tonics,  especially  strychnine, 
arsenious  acid,  quinine,  and  iron,  are  useful  in  some  cases. 

ANAESTHESIA  OP  THE   LARYNX. 

Anaesthesia  of  the  larynx  consists  in  more  or  less  complete  loss  of 
sensibility  of  the  mucous  membrane,  usually  characterized  by  dysphagia, 
which  results  from  the  tendency  of  food,  especially  liquid,  to  drop  into 
the  trachea  during  deglutition.  The  anaesthesia  may  be  unilateral  or 
bilateral;  it  maybe  almost  complete  over  the  entire  surface,  even  extend- 
ing into  the  trachea,  or  it  may  be  confined  to  that  portion  of  the  larynx 
about  the  vocal  cords. 

Etiology. — The  affection  seems  to  result  form  hysteria  in  a  few 
cases,  but  is  generally  caused  by  diphtheria  or  bulbar  paralysis.  In 
some  instances  it  has  been  due  to  tumors,  hemorrhages,  or  deposits  at 
the  base  of  the  brain  (McBride:  Edinburgh  Medical  Journal,  July,  1885; 
and  Schech :  Diseases  of  the  Nose  and  Throat) ;  it  may  follow  erysi- 
pelatous and  variolous  affections  of  the  throat,  and  has  been  observed  in 
cholera. 

Symptomatology. — The  most  important  symptom  is  spasmodic 
cough  on  deglutition,  caused  by  liquid  or  food  entering  the  trachea  and 
coming  in  contact  with  the  sensitive  membrane  beyond  the  affected 
area.  The  epiglottis  is  generally  found  erect,  and  imperfectly  closes  the 
larynx  during  deglutition. 

Diagnosis. — A  history  of  diphtheria  or  bulbar  paralysis,  with  occur- 
rence of  spasmodic  cough  on  deglutition,  and  the  absence  of  obstructions 
in  the  pharynx  or  oesophagus  as  determined  by  inspection  and  by  the 
passage  of  an  oesophageal  bougie,  are  strongly  suggestive  of  this  condi- 
tion. Palpation  with  the  laryngeal  probe  without  causing  appreciable 
sensations  renders  the  diagnosis  certain. 

Prognosis. — Except  in  cases  of  bulbar  paralysis  or  other  cerebral 
disease,  recovery  may  generally  be  expected  in  from  four  to  six  weeks. 
In  extreme  cases,  unless  measures  are  taken  to  prevent  the  passage  of 
food  into  the  trachea,  it  is  apt  to  cause  fatal  pneumonia.  When  asso- 
ciated with  bulbar  paralysis,  death  results  within  a  few  months. 

Treatment.— The  employment,  three  to  six  times  a  week,  of  either 
the  galvanic  or  induced  electric  current,  or  of  static  electricity  is  to  be 
recommended.  If  either  of  the  first  two  are  used,  the  electrodes  should 
be  applied  six  or  eight  times  at  each  sitting.  Probably  the  most  im- 
portant treatment  consists  of  the  internal  use  of  strychnine  in  large  and 
increasing  doses,  until  its  physiological  effects  are  appreciated,  as  reconi- 


500  DISEASES  OF  THE  LARYNX. 

mended  for  paralysis  of  the  vocal  cords.  When  there  is  marked  diffi- 
cult v  in  swallowing,  the  patient  should  be  fed  through  the  oesophageal 
tube,  to  prevent  the  entrance  of  food  into  the  windpipe.  Owing  to 
the  anaesthesia,  special  care  is  necessary  to  avoid  the  passage  of  the  in- 
strument into  the  larynx. 

HYPERESTHESIA,    PARESTHESIA,    AND   NEURALGIA   OF 
THE   LARYNX. 

Increased  or  perverted  sensibility  of  the  larynx,  or  intermittent  pain 
in  the  organ,  without  structural  lesions,  is  most  frequently  observed  in 
preachers  and  others  accustomed  to  excessive  use  of  the  voice. 

Simple  neuralgia  is  very  rare,  and  most  cases  which  formerly  would 
have  been  classed  under  this  head  are  now  recognized  as  rheumatic. 

Anatomical  and  Pathological  Characteristics. — There  may  or 
may  not  be  congestion  of  the  mucous  membrane;  in  some  cases  even 
pallor  is  present,  especially  when  the  condition  is  associated  with  phthisis. 
If  hyperesthesia  results  from  excessive  use  of  tobacco  or  alcohol,  there 
is  usually  congestion.  Frequently  there  is  disease  of  the  glandular 
structure  of  the  pharynx  and  larynx,  or  base  of  the  tongue. 

Etiology. — Hyperesthesia  usually  results  from  excessive  use  of 
tobacco  or  alcohol,  repeated  subacute  inflammations  of  the  larynx,  gas- 
tric disturbances,  tuberculosis,  pharyngitis,  or  over  use  of  the  voice. 

Paresthesia  is  commonly  caused  by  debility,  nervous  prostration, 
hysteria,  or  hypochondriasis,  and  often  follows  the  lodgement  for  a  short 
time  of  some  foreign  substance  in  the  throat.  It  is  sometimes  one  of 
the  early  symptoms  of  phthisis  pulmonalis.  It  is  also  a  symptom  of 
enlarged  glands  or  varicose  veins  at  the  base  of  the  tongue.  Neuralgia 
is  attributed  to  similar  causes,  but  is  more  often  due  to  anemia,  gout, 
and  rheumatism. 

Symptomatology. — In  hyperesthesia,  the  larynx  is  so  abnormally 
sensitive  that  cough  is  excited  by  slight  irritation,  such  as  the  inhalation 
of  cold  air,  smoke,  or  dust,  or  the  contact  of  certain  substances  in  deglu- 
tition. It  is  frequently  attended  by  various  sensations,  as  of  burning, 
prickling,  dryness,  rawness,  and  constriction;  and  occasionally  by  spas- 
modic action  of  the  muscles  of  the  larynx  and  pharynx,  the  former  oc- 
curring with  respiration,  the  latter  with  deglutition.  The  most  fre- 
quent sensation  in  paresthesia  is  that  of  a  silver,  or  other  large  or  small 
foreign  body  in  the  throat.  Numbness  and  coldness  are  sometimes 
experienced.  The  so  called  globus  hystericus  is  a  familiar  form  of  the 
affection.  In  neuralgia,  the  pain  is  often  intermittent  and  unilateral 
and  may  be  accompanied  by  areas  or  points  of  tenderness.  Cough  may 
be  troublesome. 

Diagnosis. — The  diagnosis  must  be  based  upon  the  symptoms,  and 
the  absence  of  physical  signs. 


CHOREA   LARYNGIS.  501 

Prognosis. — The  affections  may  be  expected  to  continue  for  a  long 
time.,  but,  in  the  majority  of  cases,  recovery  eventually  takes  place, 

Treatment. — When  hyperemia  is  present,  it  should  be  reduced  by 
stimulant  or  astringent  applications.  Diseased  glands  and  enlarged 
veins  of  the  pharynx  or  base  of  the  tongue  are  best  destroyed  with  the 
galvano-cautery.  Applications  to  the  larynx  once  or  twice  daily,  by 
spray,  of  solutions  of  morphine  or  cocaine,  though  the  latter  should  not 
be  used  freely,  or  a  combination  of  morphine,  carbolic  acid,  and  tannic 
acid  with  glycerin  and  water  (Form.  93,  139),  are  often  serviceable. 

Where  cough  is  troublesome,  troches  of.  lactucarium  or  of  cannabis 
indica  and  codeia  (Form.  29,  33)  or  other  sedative  preparations  are 
especially  useful.  Sometimes  the  inhalation  of  a  few  whiffs  of  chloro- 
form, which  may  be  carried  in  a  small  bottle  in  the  pocket,  gives  great 
relief.  Internally,  the  iodides  and  colchicum  are  indicated  when  a  rheu- 
matic or  gouty  diathesis  exists,  and  camphor  monobromide,  chloral  or 
aconite,  or  the  bromides,  gr.  x.  to  xv.,  three  or  four  times  daily  are  es- 
pecially useful  for  prolonged  sedative  effects.  The  various  bitter  and 
ferruginous  tonics  are  frequently  indicated,  and  good  hygienic  condi- 
tions are  particularly  important. 

CHOREA  LARYNGIS. 

Chorea  laryngis  is  an  extremely  rare  affection  of  the  larynx,  charac- 
terized by  regular  monotonous  recurrence,  during  waking  hours,  of  a 
peculiar  sound,  often  resembling  a  short  bark  or  yelp,  associated  with, 
and  dependent  upon  violent  inco-ordinate  involuntary  movements  of  the 
vocal  bands.  The  affection  is  accurately  described  by  Ziemssen,  but  the 
first  published  uncomplicated  case  appears  to  be  that  reported  by  G-eorge 
M.  Lefferts  (Transactions  of  the  American  Laryngological  Association, 
1879).  Cases  have  also  been  reported  to  the  same  association  by  F.  I. 
Knight,  of  Boston,  and  E.  Holden,  of  Newark,  IS".  J. 

Anatomical  and  Pathological  Characteristics. — The  disease 
is  a  neurosis  the  seat  of  which  appears  to  be  either  in  the  brain  or  spinal 
cord,  but  the  exact  lesion  has  not  been  determined.  The  larynx  is  liable 
to  be  slightly  hyperseniic,  but  presents  no  other  physical  changes. 

Etiology. — In  most  of  the  cases  reported  there  has  been  no  assign- 
able cause  for  the  affection,  which  has  come  on  in  persons  otherwise  per- 
fectly well.  It  is  sometimes  attributed  to  hysteria,  with  which  it  is 
liable  to  be  confounded. 

Symptomatology. — The  affection  may  be  a  part  of  general  chorea, 
but  the  term  chorea  laryngis  should  be  limited  to  those  cases  in  which 
only  the  laryngeal  muscles  are  involved.  There  are  no  constitutional 
symptoms,  the  patient  complains  merely  of  the  frequent  recurrence  of 
some  peculiar  sound  at  regular  intervals  during  the  waking  hours.  In 
some  this  is  attended  by  spasmodic  cougb,  which  may  be  excited  by  the 


502  DISEASES   OF  THE   LARYNX. 

act  of  swallowing.  Upon  laryngoscopic  examination,  there  is  often  found 
some  congestion  of  the  larynx,  and  in  the  intervals  between  the  pro- 
duction of  the  peculiar  sound  the  motions  of  the  cords  may  be  perfectly 
natural,  or  they  may  quiver  and  tremble,  and  the  adductors  and  abductors 
may  be  in  constant  motion ;  but,  even  then,  on  phonation  the  cords  as  a 
rule  act 'naturally ;  sometimes,  however,  during  this  act  their  move- 
ments are  irregular,  speech  being  correspondingly  altered.  At  the  time 
the  peculiar  sound  is  produced,  the  cords  are  generally  driven  suddenly 
and  sharply  together,  sometimes  two  or  three  times  in  succession ;  this 
concussion  probably  accounts  for  the  hyperemia,  and  it  is  immediately 
followed  by  a  long  inspiration  after  which  the  parts  may  remain  natural 
until  time  for  the  next  sound  to  occur.  These  peculiar  sounds  always 
cease  during  sleep. 

Diagnosis. — The  affection  is  most  likely  to  be  confounded  with 
hysteria,  from  which  it  is  distinguished  by  the  following  points: 

Chorea  laryngis.  Hysteria. 

May  accompany  general  chorea.  Absence  of  general  chorea. 

Occurs  regularly  d  u  r  i  n  g    waking  Occurs  at  irregular  periods, 
hours. 

Violent,  prolonged,  i  n  co-ordinate,  Short    spasms;    may  be    voluntary 

and  involuntary  movements.  and  regular;  never  long-continued. 

In  typical  cases,  confined  to  larynx.  Seldom  or  never  confined  to  larynx. 

Prognosis. — Under  appropriate  treatment  most  cases  recover  within 
a  few  months. 

Treatment. — Local  applications  of  electricity  have  been  tried  in 
many  cases,  but  are  of  doubtful  value.  Applications  of  astringent  sprays, 
such  as  used  in  chronic  laryngitis,  are  beneficial  in  reducing  the  hyper- 
semia,  but  the  main  reliance  must  be  placed  upon  general  tonic  treat- 
ment, especially  the  administration  of  arsenious  acid.  F.  I.  Knight 
mentions  one  case  in  which  the  symptoms  immediately  subsided  upon 
the  exhibition  of  full  doses  of  quinine  (Transactions  of  the  American 
Laryngological  Association,  1883).  Bromides  have  been  found  of  some 
benefit  in  diminishing  the  frequency  of  the  paroxysms.  Strychnine 
has  rendered  little,  if  any,  service. 

SPASM  OF  THE  VOCAL  CORDS. 

Closely  akin  to  chorea  laryngis  is  a  spasmodic  affection  of  the  vocal 
cords  most  frequently  observed  in  nervous  overworked  professional  men 
past  middle  life.  In  this  affection  there  is  commonly  congestion  of  the 
larynx,  but  no  other  visible  change  from  the  normal  condition.  The  eti- 
ology and  pathology  are  not  understood,  but  the  condition  appears  to  be 
due  to  functional  alteration  of  the  nerve  centres.  In  cases  I  have  ob- 
served the  individuals  have  been  able  at  times  to  talk  in  a  natural  voice, 


FALSETTO    VOICE.  503 

but  suddenly,  without  control,  the  voice  rises  to  a  high  pitch,  in  conse- 
quence of  spasm  of  the  adductor  and  tensor  muscles,  and  is  apparentlv 
produced  with  much  effort  and  straining  of  the  laryngeal  muscles.  In 
this  latter  respect  the  symptoms  differ  materially  from  those  attending 
paralysis  of  the  crico-thyroid  muscles,  in  which  there  is  a  somewhat  sim- 
ilar change  in  the  voice. 

The  affection  is  likely  to  continue  for  years  and  is  very  refractory. 

Teeatment. — The  treatment  from  which  most  relief  is  to  be  expected 
consists  in  good  hygienic  surroundings,  including  rest  and  pleasant  travel, 
and  systematic  vocal  culture. 

At  first  the  larynx  should  be  given,  as  nearly  as  possible,  perfect  rest 
for  several  weeks,  the  patient  talking  but'  little  and  that  only  in  a  whis- 
per. After  a  time  he  should  be  given  very  short  but  increasing  exercises 
in  reading  at  regular  hours  two  or  three  times  a  day,  as  a  sort  of  vocal 
gymnastics.  The  reading  should  be  in  a  low  unvarying  tone  and  must 
be  stopped  as  soon  as  the  voice  breaks. 

At  first  these  lessons  may  not  exceed  one  or  two  minutes  in  duration, 
but  they  may  be  gradually  prolonged  a  minute  or  more  each  day  as  the 
voice  becomes  more  stable,  and  after  the  patient  is  able  to  read  for  half 
an  hour  in  monotone,  gradual  changes  may  be  tried  in  the  pitch  and  in- 
tensity of  the  voice.  During  this  time  the  congestion  of  the  larynx  may 
be  removed  by  the  use  of  weak  astringent  sprays,  as  for  example  zinc  sul- 
phate gr.  i.-iij.  ad  3  i.  At  the  same  time  the  nervous  system  should  be 
fortiiied  by  sedatives  and  tonics  conjoined  with  abundant  rest,  regular 
exercise,  and  the  removal  of  all  sources  of  direct  or  reflex  irritation. 

FALSETTO   VOICE. 

Falsetto  voice  is  a  rare  symptom,  usually  observed  in  young  men  who, 
although  fully  developed  in  every  other  respect,  retain  an  abnormally 
high  pitched,  puerile  voice. 

It  is  due  to  the  misuse  or  non-use  of  muscles  controlling  the  lower 
register,  which  should  be  brought  into  activity  about  the  age  of  puberty. 
The  condition  is  usually  outgrown  within  a  few  months,  or  at  most  years, 
after  puberty;  but  it  sometimes  persists  to  middle  or  even  advanced  life. 
It  is  purely  functional  and  may  generally  be  speedily  cured  if  proper 
methods  are  adopted ;  but  if  left  to  themselves  such  patients  often  suffer 
for  many  years  from  the  mortification  entailed  by  the  childish  or  femi- 
nine voice. 

Tkeatment. — The  work  of  the  physician  consists  in  demonstrating 
to  the  patient  that  he  has  a  chest  voice  and  inducing  him  to  use  it. 

The  method  recommended  by  J.  C.  Mulhall,  of  St.  Louis  (Transac- 
tions of  The  American  Laryngological  Association,  1888)  I  have  found 
perfectly  satisfactory  in  several  cases.  At  first  a  thorough  laryngoscopic 
examination  is  made,  and  then  the  patient  is  assured  that  the  vocal  appa- 
ratus is  normal  and  that  if  he  will  carefully  follow  directions  he  will  with 
a  little  training  be  completely  cured. 


504  DISEASES  OF  THE   LARYNX. 

He  is  then  caused  to  depress  the  chin  firmly  on  the  neck,  and  asked  to 
imitate  the  physician,  who  sounds  a  deep  chest  tone.  The  imitation  is 
usually  prompt  and  easy.  The  patient  is  thus  shown  that  he  has  another 
voice,  and  by  repeated  exercises  taught  to  use  it.  The  depression  of  the 
chin  is  merely  to  direct  the  patient's  will  more  easily  to  the  proper  mus- 
cles, and  may  soon  be  omitted  in  subsequent  exercises. 

A  cure  may  often  be  effected  within  a  few  minutes,  though  in  other 
cases  more  prolonged  training  is  necessary.  A  few  lessons  have  always 
proven  sufficient  in  my  experience. 

Sometimes  the  cure  is  delayed  by  the  patient's  fear  to  use  his  newly 
found  voice,  or  by  embarrassment  in  using  it  before  his  acquaintances. 

LARYNGEAL  VERTIGO. 

Laryngeal  vertigo  is  a  rare  affection  characterized  by  momentary 
loss  of  consciousness,  occurring  during  a  fit  of  coughing.  It  is  usually 
observed  in  men  past  middle  life.  The  attack  generally  comes  on  sud- 
denly, with  short  spasmodic  cough,  which  is  immediately  followed  by 
giddiness.  In  most  instances,  during  the  attack,  the  patient  becomes 
unconscious  for  a  few  seconds;  but  this  speedily  passes  off,  so  that  men- 
tal confusion  remains  only  a  short  time,  excepting  in  a  small  percentage 
of  cases.  Usually  there  are  no  other  evidences  of  nervous  disease. 
During  the  attack,  the  face  may  be  unnaturally  pale,  though  in  most 
cases  it  is  congested,  and  in  a  few  there  are  twitchings  of  some  of  the 
muscles;  but  in  none  has  there  been  frothing  of  the  mouth  or  biting  of 
the  tongue,  as  in  epilepsy.  In  the  majority  of  cases,  the  larynx  has  been 
found  hypergemic. 

Most  cases  have  been  relieved,  at  least  temporarily,  by  the  applica- 
tion of  astringents  to  the  pharynx  and  larynx,  counter  irritation  over 
the  larynx,  and  the  administration  of  bromides  internally. 

A  very  full  exposition  of  the  whole  subject  has  been  given  by  F.  I.  Knight, 
in  the  Transactions  of  the  American  Laryngological  Association  for  1886. 


CHAPTEE   XXIX. 

DISEASES   OF   THE   LARYNX.— Continued. 

PARALYSIS  OF  THE  THYROEPIGLOTTIC  AND  ARY-EPIGLOTTIC 

MUSCLES   (DEPRESSORS   OP  THE   EPIGLOTTIS). 

A  paealysis  in  the  domain  of  the  superior  laryngeal  nerve  is  char- 
acterized by  dysphagia  especially  of  fluid,  and  when  complete  and  bi- 
lateral, by  anaesthesia  of  the  laryngeal  mucous  membrane.  It  is  usually 
attended  by  paresis  of  the  crico-thyroid  muscles. 

Etiology. — -The  paralysis  named  is  most  commonly  caused  by  diph- 
theria, occasionally  by  progressive  bulbar  paralysis,  and  rarely  by  enlarged 
glands  and  inflammation  of  the  areolar  tissue  beneath  the  angle  of  the 
jaw. 

Symptomatology. — In  consequence  of  this  paralysis,  the  epiglottis 
remains  erect  during  deglutition,  and  fluids  or  particles  of  food  find 
their  way  into  the  larynx  and  trachea,  where  they  cause  sudden  parox- 
ysms of  cough  and  dyspnoea  attended  by  pain  if  anaesthesia  is  not  also 
present.  Particles  of  food  aspirated  into  the  smaller  bronchi  are  apt  to 
excite  pneumonia.  Though  there  are  no  characteristic  signs  _  of  this 
affection,  upon  inspection  the  epiglottis  may  be  seen  to  maintain  an 
erect  position  during  the  imperfect  acts  of  deglutition  made  with  the 
mouth  open  and  the  tongue  protruded,  and  upon  palpation  anaesthesia 
is  often  detected. 

Diagnosis. — When  the  affection  follows  diphtheria,  it  is  usually  asso- 
ciated with  paralysis  of  the  palate  or  pharynx  and  anaesthesia  of  the 
larynx.  The  symptoms  and  signs,  taken  in  connection  with  dysphagia, 
paroxysms  of  cough  and  dyspnoea,  and  the  appearance  of  the  epiglottis, 
together  with  the  absence  of  other  signs,  establish  the  diagnosis. 

Prognosis. — In  complete  paralysis  of  both  superior  laryngeal  nerves 
there  is  considerable  danger,  but  unilateral  paralysis  is  not  very  serious. 
In  the  former,  death  may  result  from  pneumonia  caused  by  aspiration 
of  foreign  substances  into  the  lung;  but  if  this  accident  is  escaped,  the 
cases  due  to  diphtheria  usually  recover. 

Treatment. — The  greatest  care  should  be  taken  to  prevent  the  en- 
trance of  foreign  substances  into  the  trachea.  Feeding  should  be  ac- 
complished either  by  the  oesophageal  tube,  or  by  having  the  patient 
during  deglutition  assume  a  position  with   the   head  lower  than  the 


506  DISEASES  OF  THE  LARYNX. 

body.     Ferruginous  and  bitter  tonics  fire  indicated,  but  strychnine  in 
large  doses  as  advised  for  anaesthesia  of  the  larynx  is  of  most  value. 


PARALYSIS  OF  THE  CRICOTHYROID   MUSCLES  (external 

TENSORS   OF  THE   VOCAL   CORD). 

As  a  separate  affection,  paralysis  of  the  crico-thyroid  muscles  is  rare. 
It  is  either  unilateral  or  bilateral  in  its  occurrence,  and  is  characterized 
by  dysphonia  or  aphonia.  It  commonly  results  from  diphtheria,  ex- 
posure of  the  neck  to  cold  draughts,  or  from  overstraining  the  voice  in 
singing  or  shouting,  especially  during  inflammation  of  the  larynx.  It 
has  been  caused  by  injury  to  a  small  branch  of  the  superior  laryngeal 
nerve  in  ligating  the  common  carotid  artery,  and  it  is  sometimes  associ- 
ated with  paralysis  of  the  adductors  and  internal  tensors  of  the  cords. 
Complete  paralysis  of  these  muscles  is  very  rare. 

Symptomatology. — The  voice  may  be  very  hoarse  and  inadequate 
to  the  production  of  the  high  notes,  or  altogether  suppressed.  Some- 
times during  ordinary  conversation  there  is  a  peculiar  sliding  rise  in 
the  pitch  of  the  voice,  which  the  patient  is  unable  to  prevent.  Pro- 
longed use  of  the  voice  may  be  fatiguing  or  even  painful.  There  are 
also  symptoms  of  coexistent  anaesthesia  of  the  larynx.  Sometimes  by 
placing  the  finger  over  the  crico-thyroid  muscle  at  the  lower  lateral  por- 
tion of  the  larynx  during  phonation,  its  non-contraction  may  be  readily 
recognized.  In  some  instances  there  is  congestion,  in  others  a  pearly, 
translucent  appearance  of  the  vocal  cords,  which  also  have  visible 
longitudinal  relaxation. 

In  well  marked  cases  the  glottis  presents  a  peculiar  wavy  outline 
(Fig.  181),  with  a  slight  depression  of  the  central  portion  of  the  cords  in 
inspiration  and  a  corresponding  elevation  in  expiration  and  vocalization; 
the  vocal  process  can  seldom  be  seen.  When  the  affection  is  unilateral, 
the  corresponding  cord  remains  on  a  higher  level  than  its  fellow. 

Diagnosis.— In  moderate  cases  the  diagnosis  must  rest  largely  upon 
the  symptoms;  where  the  paralysis  is  decided,  the  subjective  symptoms 
and  the  appearance  of  the  glottis,  together  with  lack  of  tension  of  the 
crico-thyroid  muscle,  leave  no  doubt. 

Prognosis. — Most  cases  recover  after  a  short  time,  from  rest  alone, 
but  the  restoration  of  the  voice  may  be  aided  by  appropriate  treat- 
ment. 

Treatment. — In  slight  cases,  wet  compresses  or  mild  counter  irrita- 
tion is  all  that  is  necessary.  In  those  more  marked,  daily  applications 
over  the  muscles,  of  the  faradic  or  galvanic  currents  will  be  found  bene- 
ficial. Strychnine  and  other  tonics  are  also  indicated  in  some  cases. 
When  anaesthesia  of  the  larynx  coexists,  food  should  be  introduced 
through  an  oesophageal  tube  to  prevent  its  passage  into  the  trachea. 


PARALYSIS  OF  THE  THYRO-ARYTENOID  MUSCLES.        507 
PARALYSIS   OF   THE   THYROARYTENOID   MUSCLES   (INTERNAL 

TENSORS   OF  THE   VOCAL   CORDS). 

Paralysis  of  the  thyroarytenoid  muscles  is  a  common  affection,  which 
may  be  either  unilateral  or  bilateral.  It  is  often  associated  with  pa- 
ralysis of  the  crico-thyroids  and  the  adductor  muscles  of  the  cords.  It  is 
characterized  by  harshness  and  high  pitch  of  the  voice,  with  fatigue 
and  sometimes  jjain  in  its  use,  and  is  most  frequent  among  singers. 

ANATOMICAL    AND     PATHOLOGICAL     CHARACTERISTICS. — The     COrds 

are  often  congested,  sometimes  swollen,  and  the  edges  are  not  accurately 
approximated  but  leave  an  elliptical  chink  between  them  in  phonation, 
which  accounts  for  the  hoarseness  or  aphonia. 

Etiology. — The  affection  usually  results  from  over-use  of  the  voice 
when  the  larynx  is  inflamed,  or  at  the  period  of  adolescence  when  the 
voice  is  changing,  but  it  may  be  caused  by  a  simple  cold,  fatigue,  or 
strain  of  the  muscles,  and  occasionally  by  diphtheria  or  hysteria. 

Symptomatology. — There  may  be  fatigue  or  even  pain  upon  use  of 
the  voice,  with  dysphonia,  or,  in  case  other  muscles  are  involved,  aphonia. 


Fig.  181.— Bilateral  Paralysis  of  the  Fig.  182. — Acute  Laryngitis.    Paraljsis  of 

Crico-Thyroid  Muscles  (Mackenzie).  the  thyro-arytenoid  muscles. 

Upon  inspection  during  phonation,  an  elliptical  chink  about  a  line  in 
width  is  usually  observed  between  the  vocal  cords  (Fig.  182),  which,  to- 
gether with  other  portions  of  the  larynx,  are  liable  to  be  congested. 
When  the  arytenoid  muscle  is  also  paralyzed,  the  laryngeal  picture  is 
peculiar,  an  elliptical  chink  appearing  in  front  of  the  vocal  processes, 
and  a  more  or  less  triangular  opening  behind  them  (Fig.  183). 

Diagnosis. — The  diagnosis  is  based  upon  the  history,  symptoms,  and 
laryngoscopic  appearance. 

Prognosis. — When  associated  with  simple  laryngitis,  provided  the 
paralysis  is  not  complete,  recovery  usually  takes  place  within  a  short 
time,  but  some  cases  extend  over  several  months,  and  occasionally  the 
paralysis  is  permanent. 

Treatment. — In  over-fatigue  and  in  cases  resulting  from  acute  in- 
flammation, rest  for  the  voice,  with  soothing  inhalations  or  feeble  astrin- 
gent sprays,  are  most  beneficial.  In  some  instances,  especially  where 
fatigue  is  the  cause,  prolonged  rest  for  many  months  is  necessary. 
When  the  affection  has  already  extended  over  several  weeks,  astringent 
or  stimulating  sprays  to  the  larynx  should  be  used;  but  if  contraction  of 


DISEASES   <>F  THE  LAJiYNJT. 


the  muscles  is  not  readily  induced  in  this  way,  the  galvanic  or  faradic 
current  should  be  employed  for  a  few  moments  daily.  Bitter  and  fer- 
ruginous tonics  may  be  useful,  but  of  all  remedies  strychnine-  in  large 
doses  is  most  beneficial. 


BILATERAL   PARALYSIS   OF   THE    LATERAL    CRICOARYTENOID 

MUSCLES   (ADDUCTORS   OF   THE   VOCAL   CORDS). 

Synonyms. — Functional  aphonia,  hysterical  or  nervous  aphonia. 

In  bilateral  paralysis  of  the  lateral  crico-arytenoid  muscles,  the  vocal 
cords  act  imperfectly  and  are  not  approximated  accurately  during  at- 
tempted phonation.  It  is  characterized  by  loss  of  voice,  and  is  most 
commonly  observed  in  young  women.  It  is  often  associated  with  paral- 
ysis of  the  arytenoid  muscle,  and  sometimes  the  posterior  crico-arytenoid 
muscles  of  both  sides. 

Etiology. — The  affection  is  caused  by  hysteria,  anaemia,  general  de- 
bility,  phthisis,   ami    sometimes  by  simple  catarrhal    inflammation   in 


•v«^ 


Fig.  183.— Paralysis  of  the  Thyro- 
arytenoid Muscles  and  Partial  Paral- 
ysis of  the  Arytenoid. 


Fig.  ]S4  —  Paralysis  of  the  Lateral 
Cfico-Arytenoid  Muscles.  Attempted 
phonation. 


wMch  the  congestion  disappears,  but  the  paralysis  remains.  It  is  prob- 
ably due  in  some  instances  to  lead  or  arsenical  poisoning. 

Symptomatology. — Functional  aphonia  often  comes  on  suddenly 
without  apparent  cause,  but  sometimes  is  excited  by  shock  or  fright. 
Occasionally  a  patient  who  has  retired  in  perfect  voice  finds  herself 
unable  to  speak  in  the  morning.  In  other  cases  resulting  from  an 
acute  cold,  hoarseness  comes  on,  gradually  growing  worse  for  twenty- 
four  or  thirty- six  hours,  until  the  voice  is  lost.  Occasionally  exposure 
to  a  draught  of  air  marks  the  beginning  of  the  disease.  Xot  very 
rarely  the  affection  is  intermittent,  the  voice  failing  and  returning 
every  few  days  for  a  time.  In  some  of  these  instances  it  is  possibly 
of  malarial  origin.  One  peculiar  feature  of  many  cases  is  that  while 
voluntary  movements  of  the  cords  may  be  lost,  the  reflex  often  remain, 
so  that,  although  the  patient  cannot  speak,  she  may  cough,  sneeze,  or 
laugh  aloud.  Sometimes  such  patients  talk  aloud  in  their  sleep,  but 
are  unable  to  do  so  when  awake.  When  the  paralysis  is  complete,  no 
sound  is  caused  by  laughing  or  coughing. 

The  larynx  is  often  paler  than  natural,  but  in  catarrhal  cases  it  is 


BILATERAL  PARALYSIS. 


509 


congested.  Upon  attempts  at  phonation,  the  vocal  cords  remain  in  the 
respiratory  position  (Fig.  184)  or  move  but  imperfectly  toward  the 
median  line;  sometimes  one  is  more  completely  paralyzed  than  the 
other.  Usually  on  attempted  phonation  the  cords  are  approximated  to 
within  about  one-eighth  of  an  inch  of  each  other,  and  in  not  a  few 
cases  the  edges  may  touch  for  a  moment,  and  a  short  sound  of  a  may  be 
emitted  at  the  time,  though  the  patient  is  otherwise  unable  to  talk.  In 
complete  paralysis,  the  glottis  remains  widely  open  without  movement 
of  the  vocal  cords  during  attempted  phonation,  and  where  the  abductors 
are  also  involved  the  cords  maintain  the  cadaveric  position  midway  be- 
tween phonation  and  inspiration.  J.  Solis  Cohen  remarks  that  some- 
times this  form  of  paralysis  is  associated  with  loss  of  voluntary  control 
over  the  diaphragm,  and  then  not  only  is  the  loud  voice  lost,  but  the 
patient  is  also  unable  to  whisper  (Diseases  of  the  Throat,  second 
edition). 

Diagnosis. — The  affection  may  be  confounded  with  cases  in  which 
the  loss  of  voice  is  due  to  feeble  respiratory  action,  or  those  in  which 


Fig.  1K5.— Mackenzie's  Laryngeal  Electrodes. 


approximation  of  the  cords  is  impeded  by  swelling  of  the  inter-arytenoid 
folds,  or  by  morbid  growths,  cicatricial  tissue,  or  disease  of  the  crico- 
arytenoid articulation.  The  history  and  symptoms,  together  with  the 
laryngoscopic  appearance  just  described,  leave  no  room  for  doubt  as  to 
the  diagnosis. 

Treatment. — In  hysterical  eases  the  voice  may  frequently  be  re- 
stored by  very  indifferent  measures,  such,  for  example,  as  simply  intro- 
ducing a  mirror,  or  throwing  a  mild  astringent  spray  into  the  larynx: 
but  in  many  cases  prolonged  use  of  the  faradic  current  to  the  affected 
muscles,  applying  one  electrode  within  the  larynx  and  the  other  without, 
will  be  necessary  to  effect  a  cure.  In  most  instances  I  have  found 
astringent  or  slightly  stimulating  applications  to  the  larynx  every 
second  day,  combined  with  the  administration  of  tonics,  most  effective; 
and  of  all  tonics  for  this  purpose,  nothing  can  compare  with  strychnine 
in  full  doses.  It  is  well  to  begin  with  about  gr.  -^  three  times  daily, 
steadily  increasing  the  dose  until  constitutional  effects  are  produced, 
which  may  not  happen  until  the  patient  is  taking  as  much  as  gr.  -^  or 


510 


DISEASES  OF  THE  LARYNX. 


even  gv.  |  at  a  dose.  When  the  physiological  symptoms  occur,  the  dose 
should  be  somewhat  decreased,  and  then  continued  in  an  amount  just 
short  of  producing  spasmodic  contraction  of  the  muscles,  until  recovery 
is  complete;  or  the  quantity  may  again  be  increased,  in  the  manner 
before  mentioned. 


UNILATERAL  PARALYSIS  OF  THE  LATERAL  CRICOARYTENOID 

MUSCLE   (LATERAL  ADDUCTOR  OF  THE   VOCAL   CORD). 

In  unilateral  paralysis  of  the  lateral  crico-arytenoid  muscle  one  cord 
remains  abducted  during  attempted  phonation,  thus  rendering  the  voice 
hoarse  or  shrill.  There  is  no  lesion  of  the  larynx  itself,  but  the  recur- 
rent laryngeal  nerve  is  generally  involved. 

Etiology. — The  affection  is  caused  in  most  cases  by  pressure  upon 
the  recurrent  laryngeal  nerve,  as  by  an  aneurism  of  the  aorta,  cancer  of 
the  oesophagus,    malignant  tumor  of  the  neck,  or  enlargement  of  the 


. 


Fig.  186.  —  Unilateral  Paral-     Fig.  187.— The  same  as  Fig. 


ysis  of  the  Left  Lateral  Crico- 
arytenoid MrscLE.  Due  to  the 
pressure  of  an  aneurism  on  the 
left  recurrent  laryngeal  nerve. 


186,  in  Phonation. 


Fig.  188.— Unilateral  Paraly- 
sis of  the  Right  Lateral  t  Irico- 
Arytenoid  Muscle,  with  Swell- 
ing of  Left  Ary-Epiglottic 
Fold.  Phonation — left  cord  mov- 
ing far  beyond  the  median  line 


deep  cervical  glands.  It  is  sometimes  caused  by  chronic  lead  or  arsen- 
ical poisoning,  by  exposure  to  cold,  or  muscular  strain,  and  not  infre- 
quently by  hysteria. 

Symptomatology. — There  are  usually  no  constitutional  manifesta- 
tions but  the  symptoms  and  signs  of  a  tumor  pressing  upon  the  recur- 
rent nerve  may  frequently  be  detected.  There  is  slight  or  considerable 
impairment  of  the  voice  with  loss  of  volume,  and,  when  paralysis  is 
complete,  aphonia.  The  sounds  produced  by  coughing,  sneezing,  or  laugh- 
ing are  always  altered  more  or  less,  and  these  acts  are  sometimes  unac- 
companied by  sound.  In  phonation,  the  affected  cord  remains  at  the 
side  of  the  larynx  (Fig.  187),  and  the  supra-arytenoid  cartilages  cross 
each  other,  the  one  from  the  sound  side  passing  in  front.  The  mucous 
membrane  covering  the  affected  cord  is  often  found  congested.  "When 
caused  by  pressure  of  a  tumor,  dysphagia  is  frequently  present. 

Diagnosis. — The  diagnosis  is  readily  made  by  laryngoscopic  exam- 
ination. 


BILA  TERA L  PARAL  ISIS. 


oil 


Tkeatmext. — The  cause  of  the  difficulty  must,  if  possible,  be  found 
and  removed.  Local  treatment  is  of  little  or  no  value.  In  a  feAV  in- 
stances, evidently  functional,  which  had  existed  for  a  number  of  months, 
I  have  brought  about  a  cure  by  the  administration  of  large  doses  of 
strychnine  when  many  other  remedial  measures  had  failed. 

PARALYSIS    OF   THE   ARYTENOID   MUSCLE   (central  adductor 

OF   THE   CORDS). 

In  paralysis  of  the  arytenoid  muscle,  owing  to  the  non-approxima- 
tion of  the  inner  surfaces  of  the  arytenoid  cartilages  in  phonation,  there 
is  gaping  of  the  posterior  or  inter-cartiiaginous  portion  of  the  rima  glot- 
tidis,  with  consequent  impairment  of  the  voice.  Congestion  of  the 
larynx  is. usually  present,  for  this  form  of  paralysis  most  frequently  re- 
sults from  acute  or  subacute  laryngitis. 


Fig.  189. — Ziemssen's  Double  and  Single  Laryngeal  Electrodes. 

Symptomatology. — Hoarseness  and  fatigue  in  talking  are  prominent 
svmptoms.  Inspection  reveals  a  triangular  opening  at  the  posterior 
part  of  the  glottis  during  phonation. 

Diagnosis. — The  diagnosis  is  readily  made  by  inspection. 

Treatment. — Stimulant  inhalations  and  astringent  applications  ap- 
propriate for  the  laryngeal  inflammation  which  coexists  are  indicated. 
In  this,  as  in  other  forms  of  paralysis  of  the  laryngeal  muscles,  if  of  long 
standing,  faradization  of  the  affected  muscles  and  the  administration  of 
strychnine  should  be  tried. 


BILATERAL  PARALYSIS  OF  THE  POSTERIOR  CRICO-ARYTENOID 

MUSCLES    (ABDUCTORS   OF  THE  VOCAL   CORDS). 

Bilateral  paralysis  of  the  posterior  crico-arytenoid  muscles  is  a 
dangerous  affection  of  the  larynx  in  which  the  vocal  cords  are  not 
drawn  aside  during  inspiration,  but  remain  near  the  median  line, 
closing  the  glottis  and  causing  stridulous  respiration  and  great  dyspnoea, 
without  alteration  of  the  voice. 


512  DISEASES  OF  THE  LARYNX. 

Anatomical  and  Pathological  Characteristics. — The  affection 
is  generally  due  to  disease  of  the  central  nervous  system,  but  may  be 
produced  by  morbid  processes  which  involve  both  pneumogastric  or 
both  recurrent  laryngeal  nerves.  The  recurrent  nerves  and  their 
branches,  and  the  muscles  themselves,  have  been  found  atrophied.  In  a 
few  cases  the  muscles  have  been  found  atrophied,  though  the  brain  and 
nerves  have  appeared  healthy. 

Etiology. — The  condition,  as  before  stated,  is  usually  caused  by  dis- 
ease of  the  central  nervous  system,  and  is  evidently  sometimes  caused 
by  syphilis,  the  lesion  of  which  may  be  central  or  along  the  course  of 
the  nerve,  or  in  the  muscle  itself.  It  is  frequently  due  to  pressure  upon 
the  pneumogastric  or  recurrent  nerves  by  goitre,  enlarged  bronchial 
glands,  or  aneurism.  Cancer  of  the  thyroid  gland  or  of  the  oesophagus 
may  have  a  similar  effect.  Occasionally  the  paralysis  seems  to  result 
from  simple  catarrhal  inflammation,  or  from  hysteria. 


Fig.  190.— Bilateral  Paralysis  of  the  Pos-  Fig.  191.— Bilateral  Paralysis  of  the  Pos- 

terior    Cricoarytenoid     Muscles— Inspira-       terior     Crico- Arytenoid     Muscles— Expira- 
tion, tion. 

Symptomatology. — The  symptoms  will  depend  upon  the  nature  and 
extent  of  the  lesion.  Since  the  filaments  of  the  recurrent  nerve  supply 
antagonistic  muscles,  those  distributed  to  either  the  adductors  or  the 
abductors  may  be  most  involved,  but  experience  shows  that  the  latter 
are  usually  implicated  first.  Where  the  function  of  the  nerve  is  com- 
pletely destroyed,  the  muscles  of  both  sides  are  paralyzed  and  the  cords 
remain  in  the  cadaveric  position,  offering  no  impediment  to  respira- 
tion, though  the  voice  is  lost.  When  the  abductor  filaments  alone  are 
affected,  the  voice  remains,  but  inspiration  is  greatly  obstructed,  and 
extreme  dyspnoea  supervenes  upon  the  slightest  exertion.  A  feeling 
of  suffocation  may  occur  not  only  on  exertion,  but  occasionally  from 
spasm  of  the  adductors,  especially  during  sleep.  Expiration  is  quiet 
and  unobstructed.  When  the  abductor  muscles  alone  are  paralyzed 
the  voice  is  not  lost,  but  it  is  usually  weak;  if  the  adductors  are  also 
implicated  to  a  certain  extent,  there  is  constantly  a  waste  of  air  in  phona- 
tion  and  the  patient  in  talking  becomes  quickly  exhausted  on  account 
of  the  great  labor  thrown  on  the  expiratory  muscles;  cough  and  expecto- 
ration are  also  difficult.  Loss  of  strength,  emaciation  and  febrile  excite- 
ment, are  frequently  though  not  always  present.  On  inspection  of  the 
larynx,  the   vocal  cords  are  seen   very  near   the  median  line;    during 


BILATERAL  PARALYSIS.  513 

respiration  the  rima  glottidis  will  measure  from  one  to  two  lines  in 
width  (Figs.  190,  191). 

On  inspiration,  the  lips  of  the  glottis  are  sucked  downward  and  in- 
ward below  their  normal  plane,  and  with  expiration,  are  forced  upward, 
the  glottis  being  somewhat  dilated,  so  that  the  air  escapes  freely.  The 
vocal  cords  and  mucous  membrane  of  the  larynx  may  be  of  a  normal 
color  or  slightly  congested. 

Diagnosis. — In  adults  the  true  nature  of  the  disease  is  at  once  sug- 
gested by  prominent  inspiratory  stridor;  the  characteristic  appearance 
of  the  glottis  on  inspiration  leaves  no  doubt  as  to  the  diagnosis,  except 
as  between  this  condition  and  adhesion  of  the  inner  surfaces  of  the  aryt- 
enoid cartilages,  which  sometimes  so  closely  resembles  it  that  in  the 
absence  of  previous  history  a  differential  diagnosis  may  be  impossible. 
This  affection  may  be  distinguished  from  spasm  of  the  adductors  as 
follows : 

Bilateral  paralysis  of  the  Spasm  of  the  adductors, 

abductors. 
Inspiratory  dyspnoea  constant ;  may  Inspiratory  dyspnoea  temporary  ;  di- 

be  increased  during  sleep.  minished  or  absent  during"  sleep. 

Vocal  cords  immovable.  Vocal  cords  more  or  less  constantly 

varying  in  tension. 

Prognosis. — The  duration  and  final  result  necessarily  depend  upon 
the  nature  of  the  lesion ;  where  the  paralysis  is  decided,  the  prognosis 
is  always  unfavorable,  and  a  fatal  result  may  occur  at  almost  any  time 
unless  tracheotomy  or  intubation  has  been  done.  It  is  only  in  a  few 
cases,  of  catarrhal,  syphilitic,  or  hysterical  origin,  that  good  results  can 
be  expected  from  medicinal  treatment. 

Treatment. — The  great  danger  from  suffocation  renders  it  neces- 
sary to  adopt  some  preventive  measure.  For  this  purpose,  an  O'Dwyer 
intubation  tube  may  be  introduced  and  worn  while  the  influence  of  in- 
ternal remedies  is  being  tried ;  but  if  this  does  not  succeed,  tracheotomy 
had  best  be  performed.  Except  when  these  patients  can  be  closely 
watched  it  is  not  safe  to  let  them  go,  even  for  a  single  day,  without  one 
or  the  other  of  these  operations.  Faradization  should  be  tried,  and 
such  remedies  used  as  are  most  likely  to  remove  the  cause,  such  as  as- 
tringent and  stimulating  sprays  in  the  catarrhal  conditions,  strychnine 
and  other  tonics  in  the  hysterical  form  or  where  there  appears  to  be 
functional  interruption  in  the  central  nervous  system,  and  the  iodides 
in  the  syphilitic  variety  or  when  the  pressure  results  from  enlarged 
glands  or  goitre. 
33 


514 


DISEASES   OF  THE  LARYNX. 


UNILATERAL  PARALYSIS  OF  THE   POSTERIOR  CRICOARYTE- 
NOID   MUSCLE    (ABDUCTOR  OF  THE  VOCAL  CORD). 

In  unilateral  paralysis  of  the  posterior  crico-arytenoid  muscle,  one 
vocal  cord  remains  in  the  median  line  during  inspiration,  with  conse- 
quent dyspnoea  and  stridulous  respiration.  It  is  due  to  lesions  similar 
to  those  which  cause  bilateral  paralysis,  but  it  most  frequently  results 
from  peripheral  causes,  as,  for  instance,  catarrhal  inflammation,  or  the 
implication  of  one  pneumogastric  or  recurrent  laryngeal  nerve  by  malig- 
nant disease,  aneurism,  or  other  morbid  growths. 

Symptomatology. — The  symptoms  are  obstructed  inspiration,  stridor 
and  dyspnoea,  and  slight  alteration  of  the  voice.  There  are  also 
present  more  or  less  irritative  fever  and  the  symptoms  of  the  primary 
disease.     On  inspection  the  affected  cord  is  seen  to  remain  stationary  at 


Fig.  192.— Unilateral  Paral- 
ysis of  the  Left  Posterior 
Crico-arytenoid— Inspiration. 


Fig.  193.— Unilateral  Paral- 
ysis of  the  Left  Posterior 
Orico-Arytenoid — Phonation. 


Fig.  194. — Anchylosis  of 
Right  Vocal  Cord— Speci- 
fic—Phonation. 


or  near  the  median  line,  while  the  movements  of  the  other  are  normal 
or  slightly  exaggerated. 

Diagnosis. — The  symptoms  and  laryngoscopic  appearance  leave  no 
question  as  to  the  diagnosis. 

Prognosis.— The  affection  is  much  less  dangerous  than  bilateral 
paralysis,  but  it  is  usually  best  to  give  a  guarded  prognosis,  since  it  is 
impossible  to  tell  how  soon  the  disease  which  has  implicated  one  nerve 
may  involve  the  other.  "When  clue  to  simple  catarrhal  inflammation, 
hysteria,  or  syphilis,  recovery  is  the  rule. 

Treatment. — If  possible,  the  cause  should  be  removed.  Faradism 
or  galvanism  and  constitutional  treatment  similar  to  that  recommended 
in  paralysis  of  both  muscles  should  be  employed. 


ANCHYLOSIS   OF  THE   ARYTENOID    CARTILAGES. 

Anchylosis  of  the  arytenoid  cartilages  is  a  rare  affection,  the  diag- 
nosis of  which  may  be  attended  with  great  difficulty,  since  it  closely 
simulates  paralysis  of  the  abductors  or  adductors  of  the  vocal  cords.  It 
should  be  suspected  whenever  we  find  immobility  of  one  or  both  cords, 
with  irregularity  of  the  cartilages;  and  should  always  be  looked  for  when 


ATROPHY  OF  THE   VOCAL  CORDS.  515 

a  patient  convalescing  from  typhoid  fever  complains  of  the  symptoms 
of  laryngeal  disease. 

Teeatmext. — If  the  condition  interferes  with  respiration,  attempts 
should  be  made  at  dilatation  by  Schrotter's  sound  or  O'Dwyer's  intuba- 
tion tubes,  and  tracheotomy  must  be  done  if  necessary. 

ATROPHY  OF  THE  VOCAL  CORDS. 

Atrophy  of  the  vocal  cords  is  extremely  rare,  and  so  far  has  not  been 
proven  by  post-mortem  evidence.  The  cords  merely  have  a  shrunken 
appearance,  or  they  may  be  so  narrow  that  although  nothing  intervenes 
to  prevent  inspection  they  cannot  be  brought  into  view. 


Diseases  of  the  Nose. 


CHAPTER  XXX. 

DISEASES   OF   THE   NASAL   CAVITIES. 
INFLUENZA. 

Synonyms. — Epidemic  catarrh,  epidemic  catarrhal  fever,  grippe. 

Influenza  is  a  specific  epidemic  fever,  characterized  by  catarrhal  in- 
flammation of  the  mucous  membrane  of  the  air  passages  or  digestive 
tracts,  and  by  marked  and  sometimes  profound  disturbances  of  the 
nervous  system.  It  occurs  in  epidemics,  which  spread  rapidly  over  an 
entire  continent  and  attack  the  greater  portion  of  the  population  irre- 
spective of  age,  condition,  or  sex,  except  that  infants  enjoy  nearly  com- 
plete immunity  from  the  disease,  although  young  children  are  fre- 
quently attacked. 

Anatomical  and  Pathological  Characteristics.— No  definite 
lesions  can  be  described  as  peculiar  to  this  disease,  for  in  most  fatal 
cases  death  results  from  some  complication.  There  are  usually  signs  of 
inflammation  in  the  mucous  membrane  of  the  air  passages  and  digestive 
tract,  and  not  infrequently  in  the  serous  membranes  covering  the  brain 
or  lining  the  thoracic  or  abdominal  cavities.  Usually  upon  opening  the 
chest,  the  lungs  are  found  to  contain  here  and  there  depressed  spots  of 
lobular  consolidation.  The  mucous  membrane  of  the  larynx,  trachea, 
and  bronchial  tubes  is  congested,  swollen,  and  more  or  less  covered  with 
frothy  or  muco-purulent  secretion.  The  bronchial  glands  may  be  en- 
larged and  softened.  Firm,  whitish  clots  are  often  found  in  the  right 
side  of  the  heart.  In  many  instances  the  gastro-intestinal  mucous 
membrane  is  distinctly  congested  and  swollen  in  patches. 

Etiology. — The  disease  is  evidently  caused  by  some  powerful  mor- 
bific agent  in  the  atmosphere,  but  whether  an  irritating  gas  or  a  spe- 
cific micro-organism  has  not  been  determined.  Generally  sjaeaking,  the 
disease  cannot  be  communicated  from  one  to  another,  and,  though  some 
observations  seem  to  indicate  its  contagious  nature,  this  is  still  an  open 
question. 

Symptomatology. — The  affection  is  sometimes  preceded  for  twenty- 
four  or  forty-eight  hours  by  general  malaise,  but  usually  it  comes  on  sud- 
denly with  chilly  sensations  or  distinct  rigors  alternating  with  flashes 
of  heat  and  attended  by  severe  headache,  pain  in  the  back  and  limbs, 
constriction  of  the  chest,  and  muscular  weakness.  This  is  usually  fol- 
lowed by  the  ordinary  symptoms  of  acute  coryza,  with  sore  throat,  fre- 


520  DISEASE*  OF  THE  NASAL   CAVITIES. 

quent  hacking  cough,  arid  in  many  cases  dyspnoea,  even  without  any 
affection  of  the  lungs  themselves.  There  are  paroxysms  of  sneezing  and 
sensations  of  stuffiness  in  the  head,  the  eyes  are  suffused,  and  not  infre- 
quently the  inflammation  extends  to  the  Eustachian  tubes  and  middle 
ear. 

Severe  frontal  headache  is  one  of  the  most  common  symptoms, 
and  often  there  is  great  soreness  of  the  muscles,  attended  in  many  cases 
by  sharp  neuralgic  pains;  extreme  prostration  and  great  despondency, 
■wholly  disproportionate  to  the  severity  of  the  attack,  are  often  observed, 
and  actual  delirium  or  mental  vagaries  are  present  in  many  cases.  Diz- 
ziness is  frequently  experienced  on  rising  suddenly.  Most  epidemics  of 
the  grippe  have  been  characterized  by  great  restlessness  and  insomnia, 
but  in  some  the  opposite  condition  has  been  quite  pronounced.  As 
the  disease  becomes  established,  the  face  is  often  congested,  and  occa- 
sionally jaundice,  associated  with  hepatic  tenderness,  occurs. 

The  fever  rises  rapidly  to  101°  or  102c  F.,  or  sometimes  even  to  104°  or 
!-\;  it  is  of  a  remittent  character,  usually  attended  by  profuse  sweat- 
ing. Charles  Warrington  Earle  (Archives  of  Pediatrics,  March,  1892) 
states  that  in  some  children  with  influenza  a  high  temperature  persists 
for  a  long  time  during  convalescence.  In  others  he  has  observed  a  sub- 
normal temperature,  which  in  one  instance,  in  the  axilla,  ranged  from 
93°  to  98c  F.,  for  six  days,  although  convalescence  progressed  favorably. 
The  pulse  commonly  ranges  from  90  to  100,  though  sometimes  it  runs 
much  higher.  In  the  milder  forms  of  the  disease,  the  catarrhal  inflamma- 
tion does  not  extend  below  the  larynx;  but  in  those  of  a  slightly  severer 
grade,  which  I  have  witnessed  during  the  recent  epidemics,  a  severe 
inflammation  of  the  trachea  often  occurs,  and  not  infrequently  the  in- 
flammation extends  beyond,  giving  rise  to  bronchitis  or  catarrhal  pneu- 
monia. These  changes  are  attended  by  more  or  less  dyspnoea  and  cough, 
and  are  usually  preceded  by  hoarseness.  The  cough  occurs  in  parox- 
ysms, usually  worse  at  night  or  in  the  early  morning,  and  is  at  first 
attended  by  a  frothy  or  clear  expectoration,  which  later  becomes  muco- 
purulent and  often  quite  offensive.  The  discharge  from  the  nares  is  at 
first  thin  and  watery  as  in  an  ordinary  cold;  later  it  becomes  muco- 
purulent, and  epistaxis  is  not  uncommon.  The  tongue  is  usually  coated, 
and  the  appetite  lost;  frequently  there  is  tenderness,  or  colicky  pains 
occur  which  may  be  attended  by  nausea,  vomiting  and  diarrhoea.  In 
many  instances  there  is  acute  congestion  of  the  kidneys:  the  urine  is 
often  scanty  and  not  infrequently  it  is  suppressed  for  a  few  hours. 

Inspection  of  the  nares  usually  reveals  hyperemia  and  swelling  of 
the  mucous  membrane;  and  the  mucous  membrane  of  the  fauces  is 
similarly  affected.  Upon  examination  of  the  chest,  the  signs  of  bron- 
chitis are  generally  present,  even  in  comparatively  mild  cases,  and  all 
too  frequently  the  evidences  of  pneumonia  or  pleurisy  will  be  obtained. 

Diagnosis. — Influenza  is  not  apt  to  be  mistaken  for  any  disease  ex- 


INFLUENZA.  521 

cept  acute  non-specific  rhinitis  or  inflammation  of  the  larynx,  trachea,  or 
bronchi,  from  which  it  does  not  materially  differ  except  in  its  epidemic 
nature  and  the  severity  of  the  symptoms.  Isolated  cases  of  the  latter 
frequently  precede  an  epidemic  of  influenza  four  or  five  weeks,  present- 
ing much  the  same  symptoms  and  possibly  clue  to  the  same  cause; 
but  it  must  not  be  forgotten  that  severe  catarrhal  inflammations  of  the 
upper  air  passages  are  common,  independent  of  the  peculiar  conditions 
which  cause  influenza.  Usually  the  history  of  an  epidemic,  the  severe 
headache,  mental  depression,  muscular  pains,  and  sudden  onset  of  the 
attack  render  the  diagnosis  easy.  The  symptoms  and  signs  of  compli- 
cating disorders  will  not  differ  essentially  from  the  usual  manifestations 
of  these  affections,  except  so  far  as  they  may  be  modified  by  the  fever 
and  nervous  prostration  attending  the  epidemic  disease. 

Prognosis. — The  catarrhal  symptoms  usually  begin  to  subside  in 
three  or  four  days,  and  in  mild  cases  the  patient  will  not  be  confined  to 
the  house  more  than  forty-eight  to  seventy-two  hours;  indeed,  many 
persons  continue  their  avocations  in  spite  of  the  disease.  When  the 
disease  is  more  severe,  convalescence  may  not  be  established  for  a  week 
or  ten  days,  and  in  some  the  affection  may  be  even  more  prolonged. 
This  is  especially  the  case  when  the  affection  is  complicated  by  trachei- 
tis, bronchitis,  or  pneumonia,  but  in  uncomplicated  cases  convalescence 
is  usually  fully  established  within  ten  or  twelve  days,  even  in  the  more 
severe  forms  of  the  affection.  AY  hen  occurring  in  the  very  young  or  the 
aged,  or  in  persons  greatly  debilitated  from  any  cause,  or  in  persons 
suffering  from  chronic  pulmonary,  cardiac,  or  renal  disease,  influenza 
must  be  regarded  as  a  grave  affection ;  and  when  its  various  complicat- 
ing disorders  are  considered,  it  will  be  found  that  a  considerable  num- 
ber of  cases,  probably  three  or  four  per  cent,  prove  fatal.  When  it  at- 
tacks pregnant  women,  abortion  is  liable  to  follow.  The  experience  of 
the  epidemics  through  which  we  have  passed  during  the  last  two  years 
shows  that  functional  disease  of  the  heart,  protracted  fevers  of  a  typhoid 
character,  pleuris3r,  and  pulmonary  tuberculosis  are  common  sequels  of 
influenza.  Eheumatoid  or  neuralgic  pains  not  infrequently  continue 
many  weeks  after  the  subsidence  of  the  acute  symptoms. 

Treatment. — No  positive  directions  can  be  given  for  the  prevention 
of  the  disease;  but  as  it  has  been  observed  that  those  who  are  exposed  to 
the  outer  air  suffer  most  from  the  affection,  it  is  wise,  during  epi- 
demics, for  children  and  those  enfeebled  by  age  or  disease  to  remain  as 
much  as  possible  indoors,  hoping  thereby  to  escape.  As  the  main 
symptoms  indicate  great  nervous  depression,  it  is  well  during  an  epi- 
demic to  fortify  the  system  against  an  attack  by  tonic  doses  of  quinine 
and  nux  vomica.  Large  doses  of  quinine  are  said  sometimes  to  abort 
the* attack,  and  the  same  has  been  claimed  for  opiates,  or  opiates  in  com- 
bination with  quinine,  or  ipecacuanha.  During  the  progress  of  the  dis- 
ease, rest  in  bed  and  gentle  laxatives,  refrigerant  drinks,  moderate  doses  of 


5*22  DISEASES   OF  THE  NASAL   CAVITIES. 

quinine,  and  small  doses  of  opium  or  other  anodynes  to  relieve  tiie  cough 
are  recommended.  To  relieve  the  pain  in  the  inception  of  the  disease 
no  remedy  has  seemed  to  me  more  valuable  than  phenacetin;  later,  large 
doses  of  potassium  bromide,  which  is  peculiarly  efficient  in  allaying  irri- 
tabilitv  and  quieting  cough,  together  with  extract  of  mix  vomica,  ex- 
tract of  hyoscyamus,  quinine,  and  camphor,  have  proven  most  bene- 
ficial. The  irritability  and  inflammation  of  the  mucous  membrane  may 
sometimes  be  greatly  relieved  by  the  inhalation  of  steam,  or  steam  im- 
pregnated with  various  soothing  vapors,  as  of  opium,  belladonna,  or 
hyoscyamus.  When  rheumatic  symptoms  are  present,  colchicum  and 
the  salic}-lates,  together  with  alkalies,  have  been  found  most  useful. 
Complicating  diseases  should  be  treated  upon  general  principles,  and 
in  protracted  cases  the  nutrition  should  be  carefully  attended  to.  If 
convalescence  is  delayed,  a  change  of  climate  will  frequently  be  of  great 
advantage. 

RHINITIS. 

SIMPLE   ACUTE    RHINITIS. 

Synonyms. — Acute  coryza,  acute  nasal  catarrh,  acute  cold  in  the 
head,  acute  rhinorrhcea. 

Simple  acute  rhinitis  is  an  inflammation  of  the  nasal  mucous  mem- 
brane, sometimes  of  one  passage,  but  usually  of  both,  often  extending 
into  the  maxillary  or  frontal  sinuses,  the  lachrymal  ducts,  and  Eusta- 
chian tubes.  It  is  characterized  by  paroxysms  of  sneezing,  hyper- 
secretion, and  more  or  less  obstruction  of  the  nares.  In  infants  it  causes 
marked  difficulty  of  breathing,  particularly  during  sleep  or  nursing,  and 
is  occasionally  attended  by  attacks  very  closely  resembling  laryngismus 
stridulus.  The  disease  occurs  in  all  climates  and  seasons  and  among 
patients  of  all  ages  and  all  classes  of  society,  but  it  is  somewhat  more 
frequent  among  children,  some  of  whom  apparently  have  a  congenital 
predisposition  to  it.  It  is  said  to  be  more  frequent  among  persons  of 
nervous  temperament  and  in  those  subject  to  rheumatism,  yet  it  is  usu- 
ally independent  of  diathesis. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membrane  becomes  swollen,  red,  and  at  first  dry,  but  is  soon  bathed  in 
a  profuse  secretion  of  serum,  which  a  little  later  becomes  sero-purulent 
and  is  loaded  with  an  excess  of  salines,  which  are  very  irritating  to  the 
nostrils  and  upper  lip.  In  exceptional  cases  an  excess  of  fibrin  collects 
in  irregular  masses,  as  a  membranous  layer,  which  is  most  often  found 
in  the  coryza  of  new-born  infants  or  in  that  accompanying  the  exanthe- 
mata. 

Etiology. — The  most  common  cause  is  exposure  to  cold  when  the 
body  is  overheated,  but  not  infrequently  it  results  from  exposure  to 
undue  heat,  or  the  inhalation  of  dust  or  irritating  fumes   or  vapors. 


SIMPLE  ACUTE  RHINITIS.  523 

Fraenkel  believes  that  infantile  coryza  is  generally  due  to  direct  infec- 
tion from  the  vaginal  secretions  at  the  time  of  birth.  Among  the  occa- 
sional causes  may  be  mentioned  exposure  to  the  rays  of  the  sun,  im- 
petigo or  eczema,  measles,  scarlet  fever,  typhoid  fever,  tertiary  syphilis, 
iodism,  facial  erysipelas,  or  extension  of  inflammation  from  the  con- 
junctivae, pharynx,  or  larynx;  and  it  is  said  to  be  caused  in  some  in- 
stances by  the  cure  of  chronic  discharges,  such  as  those  of  otitis  and 
ophthalmia,  or  bleeding  hemorrhoids. 

Symptomatology. — The  affection  often  comes  on  with  a  feeling  of 
general  malaise,  which  may  last  for  two  or  three  days,  but  more  fre- 
quently there  is  aching  of  the  back  or  limbs  for  only  a  few  hours.  Often 
constitutional  symptoms  are  not  present,  and  the  onset  is  marked  merely 
by  an  attack  of  sneezing,  with  more  or  less  stopping  up  of  the  nose  and 
hypersecretion  of  a  thin,  irritating  serum,  which,  after  one  or  two  days, 
becomes  thicker  and  bland.  The  nostrils  and  upper  lip  become  red  and 
irritated  from  the  secretion  and  frequent  use  of  the  handkerchief.  The 
nasal  passages  are  so  stopped  that  the  patient  is  obliged  to  breathe 
through  the  mouth,  with  great  discomfort,  particularly  while  he  is  eating 
and  during  sleep. 

The  general  symptoms  vary  from  slight  disturbance  to  severe 
pain  and  headache,  with  sleeplessness,  mental  and  physical  debility, 
fever,  and  derangement  of  the  digestive  organs.  There  is  sometimes 
a  slight  chill  at  first,  but  the  earlier  symptoms  usually  consist  of 
sensations  of  dryness  or  irritation  in  the  nose  and  a  disposition  to  sneeze. 
"Within  a  few  hours  there  is  stopping  up  of  the  nares,  with  obtunding  of 
the  senses  of  smell  and  taste,  more  or  less  pain,  and  frequently  extension 
of  inflammation  along  the  lachrymal  ducts,  causing  redness  and  sensi- 
tiveness of  the  conjunctivae.  If  the  inflammation  extends  along  the 
Eustachian  tubes,  there  is  a  sense  of  fulness,  possibly  with  pain  in  the 
ears,  and  often  abnormal  auditory  sensations  and  partial  deafness.  The 
inflammation  may  travel  down  the  pharynx,  causing  sore  throat,  or  it 
may  involve  the  antrum,  frontal  sinus,  or  ethmoidal  or  sphenoidal  cells, 
causing  correspondingly  severe  pain  in  the  cheek  or  forehead,  or  deeper 
seated. 

Occasionally  the  disease  is  intermittent,  lasting  for  two  or  three 
days,  and  then  subsiding,  to  be  renewed  after  an  equal  length  of 
time.  Any  or  all  of  the  symptoms  excepting  the  secretion  may  be 
absent.  The  inflammation  frequently  attacks  one  side,  not  involving 
the  other  for  two  or  three  days  or  until  its  course  is  completed  in  the 
first.  Exceptionally  the  cervical  lymphatic  glands  become  enlarged  and 
sore.  The  body  temperature  may  rise  two  or  three  degrees  and  the 
pulse  be  correspondingly  accelerated.  Obstruction  of  the  anterior  nares 
gives  the  voice  a  nasal  tone;  but  if  the  swelling  is  mainly  in  the  posterior 
part  of  the  nares,  the  general  character  of  the  voice  is  normal,  while  the 
articulation  is  defective,  the  letter  m  being  sounded  like  b,  and  n  like  cl. 


5-^4  DISEASES   OF  THE  NASAL   CAVITIES. 

The  secretion,  which  at  first  was  thin,  serous,  and  irritating,  after  a 
time  becomes  thicker,  whitish,  yellowish,  or  greenish,  according  to  the 
intensity  of  the  inflammatory  process,  and  the  cold  is  said  to  have  broken. 
The  secretion  may  amount  to  several  ounces  in  twenty-four  hours.  The 
frequent  use  of  a  handkerchief  after  a  time  becomes  painful,  but,  as  the 
secretion  becomes  thicker,  irritation  gradually  subsides.  There  is  often 
an  unpleasant  catarrhal  odor  to  the  breath;  and  when  the  nose  is  com- 
pletely obstructed,  the  tongue  becomes  dry  and  brown  from  the  continued 
mouth-breathing.     The  appetite  is  not  infrequently  impaired. 

Upon  inspection,  the  mucous  membrane  is  found  to  be  swollen  and 
congested,  and  sometimes,  though  not  commonly,  here  and  there  are 
small,  dark-brown  stains,  indicating  extravasation  of  blood  beneath  the 
mucous  membrane;  or  slight  abrasions  of  the  surface  may  be  noticed. 
Early  in  the  attack  the  thin  secretion  may  be  seen  moistening  the  en- 
tire mucous  membrane  or  flooding  the  floor  of  the  nasal  cavity;  later, 
fine,  cobweb-like  shreds  of  mucus  are  often  seen  stretching  from  side  to 
side  across  the  nasal  chamber,  and  more  or  less  of  the  thicker  secretion, 
mucous  or  muco-purulent  in  character,  will  be  found  collected  in  the 
nasal  cavities,  especially  at  the  lower  and  back  parts. 

Diagnosis. — Acute  rhinitis  is  not  likely  to  be  confounded  with  any 
affections  excepting  hay  fever,  inflammation  of  the  antrum  or  frontal  sin- 
uses, or  the  commencement  of  measles.  In  any  case  the  history,  the 
character  of  the  discharges,  and  the  appearance  of  the  parts  will  soon 
settle  the  diagnosis. 

Prognosis. — Attacks  of  acute  rhinitis  sometimes  last  but  a  few  hours, 
but  usually  they  continue  for  from  three  days  to  a  week,  and  sometimes 
two  or  three  times  as  long.  The  stage  of  dryness  generally  continues 
two  or  three  hours,  that  of  free,  thin  secretion  from  twenty-four  to 
forty  hours.  The  thick  secretion  commonly  continues  two  or  three 
days,  when  it  gradually  grows  thinner  until  the  end  of  the  attack. 
The  affection  usually  terminates  by  resolution;  in  children  at  the 
breast,  and  in  the  very  aged  and  infirm,  it  has  occasionally  ]>roved  fatal. 
Frequently  repeated  attacks  are  liable  to  eventuate  in  a  chronic  ca- 
tarrhal condition  of  the  nasal  mucous  membrane.  The  inflammation 
may  leave  obstruction  of  the  lachrymal  ducts  or  the  Eustachian  tubes,  or 
chronic  inflammation  of  some  of  the  adjacent  sinuses,  and  it  sometimes 
seems  to  be  the  starting  point  for  nasal  polypi.  Where  these  growths 
already  exist,  they  are  often  found  to  enlarge  greatly  during  acute  at- 
tacks of  coryza. 

Treatment. — Prophylactic  treatment  includes  daily  sponging  of  the 
chest  with  cold  water  or  salt  and  water,  bathing  the  feet  every  morning  in 
cold  water,  care  respecting  sufficient  warmth  of  the  clothing;  and  avoid- 
ance of  sudden  exposure,  damp  clothing,  wet  feet,  and  in  a  word  all 
things  which  have  been  found  to  excite  the  inflammation.  In  the  be- 
ginning an   attack   may   frequently   be  aborted  by   moderately   large 


SIMPLE  ACUTE  RHINITIS.  525 

doses  of  opium,  quinine,  alcoholic  stimulants,  or  the  ammonium  salts. 
Morphine  gr.  £  to  i  or  its  equivalent,  atropine  gr.  T\^  with  morphine 
gr.  £,  pulv.  ipecac,  comp.  gr.  x.,  quinine  gr.  vi.  to  x.,  or  a  hot  sling  taken 
at  bed  time  will  frequently  abort  the  disease.  It  may  also  be  checked 
in  a  similar  way  by  one  or  two  doses  of  ammonium  carbonate,  gr.  x.  to 
xx.;  ammonium  chloride,  gr.  xx.  to  xxx.;  liquor  ammonias  acetatis,  3  L; 
tincture  of  belladonna,  TTtx.  to  xx. ;  tincture  of  euphrasia  officinalis,  tr^x. 
to  xx. ;  ammoniated  tincture  of  guaiacum,  3  i. ;  or  an  emetic  dose  of  an- 
timony. These  are  best  administered  at  bedtime,  and  their  action  may 
be  favored  by  a  hot  foot  bath  containing  a  handful  of  mustard.  Some- 
times the  disease  is  speedily  aborted  by  frequent  inhalations  of  chloro- 
form, or  the  vapor  of  ammonium  carbonate,  camphor,  iodine,  or  carbolic 
acid.  But,  as  a  rule,  the  most  satisfactory  abortive  treatment  consists 
in  the  administration  of  a  comparatively  large  dose  of  quinine,  and  the 
application  to  the  nose,  either  by  spray  or  powder,  of  a  small  quantity 
of  cocaine.  Where  opiates  are  well  borne,  one  or  two  small  doses  of 
atropine  and  morphine  act  well. 

If  the  cold  has  existed  for  twenty-four  hours,  it  can  seldom  be 
aborted,  and  must  then  be  simply  carried  through  to  a  speedy  termina- 
tion, with  as  little  discomfort  as  possible  to  the  patient.  Total  absti- 
nence from  liquids,  as  recommended  by  C.  J.  D.  Williams,  is  said  to 
be  efficient  in  curing  attacks  of  acute  rhinitis  (Cyclopaedia  of  Pract. 
Med.,  London,  1833),  the  coryza  beginning  to  dry  up  in  about  twelve 
hours  after  liquids  have  been  suspended,  and  ceasing  completely  in  from 
twenty-four  to  thirty-six  hours.  Williams,  however,  allowed  a  table- 
spoonful  of  milk  or  tea  twice  a  day,  and  a  wine  glass  of  water  at  bed 
time.  If  the  disease  was  not  aborted,  Morell  Mackenzie  recommended 
five  drops  of  the  tincture  of  opium  every  six  or  eight  hours.  Ten  drops  of 
the  spirits  of  camphor  on  sugar  may  be  effectively  taken  in  the  same  way. 
Five  grain  doses  of  potassium  nitrate,  twenty  minim  doses  of  the  spirit 
of  nitrous  ether,  or  two  drachm  doses  of  solution  of  ammonium  acetate 
repeated  from  time  to  time  are  often  useful  in  cutting  short  the  disease. 

Turkish  baths  are  sometimes  very  efficient,  though  extreme  care 
is  necessary  to  avoid  taking  subsequent  cold.  Jaborandi  and  other 
diaphoretics  have  a  similar  effect,  and  diuretics  and  cathartics  may 
expedite  the  cure;  however,  these  should  only  be  given  when  the 
patient  can  be  kept  indoors.  Inspiration  through  the  nose  of  warm 
aqueous  vapors  or  sprays  of  mild  solutions,  gr.  ij.  ad  3  i.,  of  ammonium 
chloride  or  carbonate,  or  sodium  bicarbonate,  or  potassium  carbonate,  or 
boric  acid,  gr.  viij.  ad  3  i.,  are  sometimes  very  grateful  to  the  patient, 
and  seem  to  aid  much  in  prompting  resolution. 

As  a  rule,  the  most  satisfactory  course  of  treatment  will  be  found  in 
the  administration  at  first  either  of  the  morphine  and  atropine  or  of  a 
comparatively  large  dose  of  quinine  or  of  nux  vomica  and  the  application 
to  the  nares  of  a  one  or  two  per  cent  solution  of  cocaine  in  water,  or  better 


526  DISEASES   OF  THE  NASAL    CAVITIES. 

still  in  oil,  or  the  insufflation  of  a  powder  of  four  per  cent  of  cocaine  in 
sugar  of  milk  and  starch.  In  the  latter  case  it  is  well  to  use  also  a 
spray  of  liquid  alholene  or  benzoinol  three  or  four  times  daily. 

Occasionally  persons  are  met  in  whom  oily  sprays  of  any  kind  aggravate  the 
disease.     In  these  the  solution  of  boric  acid  is  apt  to  be  most  soothing. 

If  the  disease  is  not  aborted  at  once,  the  cocaine  may  be  continued  in 
small  quantities  three  or  four  times  a  day.  The  spray  of  liquid  albolene 
should  be  continued  during  the  attack,  and  the  patient  may  be  given 
with  advantage,  four  or  five  times  daily,  small  doses  of  cannabis  indica 
and  hyoscyamus,  with  medium  doses  of  camphor  and  quinine,  or  quinine 
and  phenacetin,  or  quinine  and  camphor  mono-bromide.  If  opiates 
are  given,  care  should  be  taken  to  keep  the  bowels  open;  and  in  any 
event  it  may  sometimes  be  desirable  to  give  gentle  laxatives. 

Acute  rhinitis  in  infants  requires  especial  care  to  keep  the  nasal 
passages  open.  This  may  be  done  best  by  the  application  of  sprays  of 
liquid  albolene,  or,  in  cases  where  there  is  extensive  secretion,  by  syring- 
ing the  nose  with  a  warm  alkaline  solution.  The  washing  must  be 
performed  very  carefully,  and  it  must  not  be  forgotten  that  often 
even  very  mild  solutions  are  irritating  to  the  nares  and  give  the  child 
pain.  Whenever  it  is  deemed  necessary  to  syringe  the  nares  in  a  child, 
it  should  be  placed  upon  the  face,  and  the  warm  solution  introduced 
slowly,  so  that  it  may  run  out  again  from  the  opposite  nostril,  and  not  be 
drawn  into  the  larynx.  Excepting  opium,  most  of  the  remedies  rec- 
ommended in  the  treatment  of  the  disease  in  adults  may  be  used  in 
smaller  quantities  for  children,  but  usually  it  is  best  to  rely  upon  oily 
sprays  and  small  doses  of  quinine,  with  medium  doses  of  the  solu- 
tion of  ammonium  acetate.  Tincture  of  euphrasia  officinalis  given  in 
small  and  frequent  doses  is  said  to  be  peculiarly  effective  in  the  onset. 

TRAUMATIC    RHINITIS. 

Inflammation  of  the  mucous  membrane  is  not  infrequently  excited 
by  dust  and  vapors  of  chlorine,  iodine,  or  other  irritating  substances 
suspended  in  the  atmosphere.  It  may  also  arise  from  the  entrance  of 
larger  foreign  bodies,  or  may  follow  direct  injuries  to  the  nose.  The  in- 
flammation is  not  peculiar,  and  the  remedies  indicated  for  acute  simple 
rhinitis  are  equally  applicable  here,  except  in  case  of  fracture,  when  the 
parts  must  be  replaced,  and  retained  by  nasal  plugs  and  external  splints. 
Hemorrhage  should  be  controlled  by  the  measures  suggested  for  epi- 
staxis,  and  if  abscesses  result  the  pus  should  be  promptly  evacuated. 

The  acute  rhinitis  due  to  the  pollen  of  plants  or  other  irritating  par- 
ticles will  be  considered  under  the  head  of  hay  fever,  but  there  is  a 
form  dependent  upon  the  specific  effects  of  potassium  bichromate,  arseni- 
ous  acid,  and  mercury  which  deserves  special  notice  here.  It  is  charac- 
terized by  ulceration  leading  to  perforation  of  the  cartilaginous  septum. 


CHRONIC  RHINITIS.  527 

The  nicer  is  at  first  small  and  round,  but  subsequently  enlarges  and 
assumes  an  oval  shape.  Since  it  does  not  extend  to  the  lower  and  ante- 
rior part  of  the  cartilage,  the  bridge  of  the  nose  never  falls  in.  Ulcers 
are  also  occasionally  found  on  the  turbinated  bodies,  but  are  less  exten- 
sive than  those  on  the  septum. 

Symptomatology. — The  symptoms  produced  by  the  bichromate  are 
tickling  and  sneezing,  accompanied  by  profuse  secretion;  this  is  at 
first  watery,  but  subsequently  it  becomes  thick  and  greenish,  and  later 
contains  crusts  or  particles  of  sloughing  mucous  membrane,  and  finally 
pieces  of  cartilage;  but  it  is  never  offensive.  Hemorrhage  frequently 
occurs  in  the  course  of  ulceration.  The  symptoms  produced  by  the 
other  substances  are  said  to  be  similar;  and  whichever  of  these  substances 
is  the  cause,  the  symptoms  seem  to  result  entirely  from  local  irritation. 

Treatment. — -Persons  employed  in  trades  where  they  are  likely  to 
suffer  from  this  affection  should  constantly  wear  plugs  of  wool  in  the 
nostrils.  Where  perforation  has  once  taken  place,  it  is  difficult  to  pre- 
vent the  formation  of  a  large  opening,  but  ordinary  treatment  will  soon 
check  the  surrounding  inflammation.  Those  who  have  once  suffered 
from  this  variety  of  traumatic  rhinitis  are  said  afterward  to  enjoy  im- 
munity from  common  catarrh. 

CHRONIC    RHINITIS. 

Synonyms. — Rhinitis  chronica,  chronic  catarrh,  chronic  coryza. 

Chronic  rhinitis  is  a  chronic  inflammation  of  the  nasal  mucous  mem- 
brane characterized  by  dryness  and  the  collection  of  crusts,  or  excessive 
secretion  and  discharge  from  the  nostrils  or  naso-pharynx,  with  fre- 
quent inclination  to  hawk  and  clear  the  throat.  Both  conditions  may 
be  characterized  by  stoppage  of  the  nares  and  interference  with  res- 
piration. It  is  an  affection  found  in  nearly  all  climates  and  among 
all  classes  of  people,  and  is  most  pronounced  in  the  fall,  spring,  or 
winter  months,  when  the  temperature  and  moisture  of  the  air  are  most 
changeable.  It  is  most  frequently  met  with  near  the  northern  seashore 
or  on  the  borders  of  large  lakes,  yet  it  is  prevalent  even  in  some  dry 
climates,  especially  where  the  air  is  filled  with  dust,  as,  for  example,  in 
Colorado  and  New  Mexico.  On  the  borders  of  the  Great  Lakes  and  at 
the  seashore  it  is  much  more  common  among  people  who  live  within 
two  or  three  miles  of  the  water  than  among  those  farther  inland,  ap- 
parently owing  to  the  greater  exposure  of  the  former  to  sudden  changes, 
and  to  fogs  and  the  damp,  chilly  winds,  especially  in  the  spring,  when 
the  southerly  land  winds  have  become  warm  and  balmy,  while  the  north- 
erly winds  sweep  over  water  often  still  containing  ice,  and  colder  than 
the  land.  The  affection  is  most  frequent  in  children  and  young  adults 
between  the  ages  of  ten  and  thirty-five  years,  but  it  often  occurs  in  infants, 
and  not  infrequently  in  people  past  the  prime  of  life.     Persons  follow- 


528  DISEASES  OF  THE  NASAL  CAVITIES. 

ing  outdoor  vocations  become  less  susceptible  to  the  influence  of  sud- 
den atmospheric  changes,  and  are  therefore  less  liable  to  this  disease. 
For  convenience  of  description,  chronic  rhinitis  ma}-  be  divided  into 
four  varieties :  first,  simple  chronic  rhinitis,  consisting  of  catarrhal  inflam- 
mation with  little  or  no  swelling:  second,  intumescent  rhinitis,  a  phase 
of  the  disease  in  which  there  is  frequent  swelling  of  the  mucous 
membrane  of  the  turbinated  bodies  or  upper  portion  of  the  septum  in 
one  or  both  nares,  which  may  come  on  speedily  in  one  or  the  other 
side,  and,  after  a  time,  may  as  quickly  disappear,  so  that  often  when 
the  nose  is  examined  the  cavities  appear  of  normal  size,  though  one 
or  both  may  have  been  completely  closed  a  short  time  before;  third, 
hypertrophic  rhinitis,  an  inflammation  associated  with  more  or  less 
actual  hypertrophy  of  the  tissues;  fourth,  atrophic  rhinitis,  usually  the 
sequel  of  the  hypertrophic  variety,  in  which  the  mucous  and  submucous 
tissues  are  wasted  away,  and  as  a  result  the  nasal  cavities  become  abnor- 
mally large.  All  these  varieties  usually  originate  in  the  same  manner 
and  frequently  run  the  same  course  for  a  considerable  period.  The 
first  variety  is  often  but  a  commencement  of  the  second,  the  second  of 
the  third,  and  the  third  of  the  fourth;  but  there  are  occasional  instances 
in  which  either  the  second  or  third  variety  may  begin  or  terminate 
without  the  supervention  of  the  forms  which  generally  follow,  and  there 
are  occasional  cases  in  which  neither  variety  can  be  traced  to  any  ante- 
cedent affection. 

Simple  chronic  rhinitis  is  a  catarrhal  inflammation  of  the  mucous 
membrane  attended  by  little  or  no  swelling  and  characterized  generally 
by  great  irritability  and  susceptibility  to  acute  exacerbations.  It  is  at- 
tended by  congestion  and  by  excessive  watery  or  muco-purulent  secre- 
tions. 

Etiology. — The  disease  may  be  induced  by  the  frequent  repetition 
of  any  of  those  conditions  which  cause  an  ordinary  cold.  It  may  result 
from  inhalation  of  irritating  substances,  exposure  of  the  throat,  back, 
ankles,  or  of  the  whole  body  to  cold,  or  the  inhalation  of  damp,  chilly 
atmosphere.  A  predisposition  to  inflammation  of  the  mucous  mem- 
brane may  be  inherited,  or  acquired  by  frequent  attacks  of  the  acute 
disease.  Debility  and  a  depressed  condition  of  the  nervous  system  often 
directly  favor  the  onset  of  the  affection,  and  in  many  cases  hyperes- 
thesia of  the  terminal  nerve  fibres  in  the  Schneiderian  membrane  is 
apparently  the  predisposing  cause.  In  some  cases  it  is  favored  by  a 
scrofulous  or  dartrous  diathesis. 

Symptomatology. — There  is  usually  a  history  of  frequently  recur- 
ring attacks  of  acute  inflammation  which  have  finally  resulted  in  con- 
stum  irritation  that  is  likely  to  have  continued  for  months  or  years 
before  the  patient  has  applied  for  relief.  Itching,  burning,  and  tickling 
sensations  in  the  nose  are  common,  and  sneezing  usually  occurs  on  the 


CHRONIC  RHINITIS.  529 

slightest  provocation.  Headaches  and  pain  in  the  eyes  are  frequent 
symptoms.  Xot  infrequently  there  is  loss  of  the  sense  of  smell,  and 
partial  deafness ;  and  occasionally  the  sense  of  taste  is  obtunded.  Pro- 
fuse lachrymation  is  an  occasional  symptom,  and  in  most  cases  there  is 
a  profuse  watery  discharge  from  the  nose,  recurring  upon  the  slightest 
irritation  such  as  breathing  of  cold  air.  In  some  persons,  after  a  time, 
the  secretions  become  muco-purulent  and  of  a  more  or  less  offensive  odor. 

Usually  the  general  health  is  not  perceptibly  impaired,  but  some- 
times it  is  poor,  with  derangement  of  the  digestive  organs  mani- 
fested by  capricious  appetite  and  a  sluggish  condition  of  the  bowels. 
When  the  secretion  is  thin  and  watery,  the  mucous  membrane  will  gen- 
erally be  found  congested,  of  a  bright  red  color,  the  surface  moist,  and  a 
considerable  amount  of  secretion  collected  in  the  lower  part  of  the  nasal 
fossae.  Frequently  cobweb-like  threads  of  mucus  will  be  seen  stretch- 
ing from  side  to  side  of  the  nasal  cavity,  and  occasionally  small,  opales- 
cent, transparent,  or  yellowish  granulations  will  be  seen  studding  the 
anterior  ends  of  the  inferior  turbinated  body.  These  are  about  a  milli- 
metre in  diameter  and  appear  like  solid  masses,  but  when  brushed  over 
with  the  probe,  they  are  found  to  be  small  drops  of  fluid.  The  nasal  cavity 
normally  is  from  three  to  five  millimetres  in  width  but  in  more  than 
half  of  the  cases  examined,  deviation  of  the  nasal  septum  is  present,  or 
a  cartilaginous  or  bony  spur  will  be  found  projecting  from  one  or  both 
sides.  These,  however,  may  have  no  relation  to  the  catarrhal  condition, 
and  are  of  no  consequence  as  long  as  they  do  not  obstruct  nasal  respi- 
ration. In  most  instances  the  mucous  membrane  of  the  naso-pharynx 
is  congested,  and  here  and  there  collections  of  tenacious  secretions  will 
be  found  adhering  to  its  surface;  or  these  may  collect  to  be  removed 
from  time  to  time  by  the  act  of  hawking.  In  rare  instances  the  nasal 
cavity  remains  of  normal  size  and  free,  excepting  when  obstructed  by 
dry  and  decomposing  secretion ;  if  this  be  removed,  the  mucous  mem- 
brane is  found  irregularly  congested  and  of  a  bright  red  color  in  spots, 
or  pale  and  anamiic.  In  most  of  these  cases,  the  atrophic  condition  is 
present,  but  in  others  there  are  evidences  of  hypertrophy. 

Diagnosis. — The  diagnosis  may  be  easily  made  by  inspection  and 
palpation  of  the  part,  with  a  consideration  of  the  history.  This  form  of 
chronic  rhinitis  is  only  likely  to  be  mistaken  for  hay  fever.  The  latter 
comes  on  at  certain  periods  of  the  year,  and  is  repeated  season  after 
season;  while  the  former  comes  on  at  anytime, and  is  apt  to  be  continu- 
ous, with  frequent  exacerbations.  Upon  inspection  of  the  part,  the  nasal 
mucol^s  membrane  is  found  congested,  and  palpation  with  the  probe 
frequently  reveals  here  and  there  sensitive  spots,  similar  to  those  which 
are  present  in  most  cases  of  hay  fever;  but  the  hypertrophic  or  atrophic 
changes  usually  present  in  chronic  rhinitis  are  not.  so  common  in  hay 
fever. 

Prognosis. — The  affection  runs  a  tedious  course,  sometimes  lasting 
34 


530  DISEASES  OF  THE  NASAL   CAVITIES. 

for  many  years.  Some  cases  eventually  recover  spontaneously,  but 
others  go  on  from  bad  to  worse,  and  finally  terminate  in  some  of  the 
other  forms  of  chronic  catarrh. 

Treatment. — The  treatment  of  this  variety  of  rhinitis  is  tedious 
and  often  unsatisfactory,  but  usually  considerable  relief  may  be  given 
and  in  some  cases  a  cure  effected  by  local  applications.  In  the  treat- 
ment, two  objects  are  to  be  kept  in  view,  viz.,  relief  of  irritability,  and 
the  checking  of  excessive  secretion.  If  the  secretions  are  profuse  and 
watery,  the  nares  will  be  kept  clean,  so  that  washes  are  unnecessary.  In 
this  class  of  cases,  soothing  j>owders  or  sprays  are  most  efficacious,  and 
mild  astringents  will  often  be  found  useful  to  toughen  the  membrane. 
All  applications  should  be  so  mild  as  not  to  cause  smarting  for  more 
than  five  minutes,  and  should,  after  brief  discomfort,  give  a  feeling  of 
relief.  The  susceptibility  of  the  mucous  membrane  varies  greatly  in 
different  cases;  therefore  the  mildest  preparation  should  always  be  used 
in  the  beginning.  Oily  sprays  are  of  utility  in  most  cases.  Those 
most  commonly  in  use  are  derivatives  from  coal  oil,  such  as  oleum 
petrolina  and  liquid  albolene;  melted  vaselin  is  also  used  for  the  same 
purpose.  However,  the  effects  of  tbese  are  but  tentative,  and  there- 
fore they  should  only  be  prescribed  for  the  patient  to  use  at  home  two 
or  three  times  daily.  In  some  cases  of  profuse  secretion  I  have  obtained 
most  excellent  results  by  having  the  patient  apply  twice  daily  a  spray 
containing  ffl  x.  of  terebene  ad  5  i.  of  liquid  albolene.  Indeed,  this  has 
seemed  more  effective  than  any  other  local  application. 

A  sedative  powder  consisting  of  about  five  or  ten  per  cent  of  boric 
acid,  twenty-five  per  cent  of  iodol,  five  per  cent  of  starch,  and  sugar  of  milk 
to  make  one  hundred  grains,  with  occasionally  one  per  cent  of  cocaine, 
may  in  some  cases  be  applied  in  addition  to  the  spray  once  or  twice 
daily  with  much  benefit.  Certain  patients  in  whom  there  is  marked 
hyperaesthesia  of  the  nasal  mucous  membrane,  upon  going  into  the 
wind  or  dust  are  subject  to  attacks  of  sneezing,  accompanied  by  exces- 
sive secretion,  necessitating  almost  constant  use  of  the  handkerchief. 
There  is  consequently  soreness  of  the  nose,  which  becomes  the  source  of 
much  annoyance.  This  is  the  most  obstinate  variety  of  simple  chronic 
rhinitis,  but  fortunately  it  is  rare.  In  searching  for  the  sensitive  spots 
a  probe  should  be  passed  to  the  back  part  of  the  nasal  cavity  and  drawn 
forward  over  the  various  parts  of  the  mucous  membrane;  as  a  sensitive 
spot  is  touched,  the  patient  winces  from  the  pain  or  inclination  to 
sneeze  or  cough,  and  sometimes  says  that  the  probe  pricks  or  burns. 
The  most  effective  treatment  is  superficial  cauterization  of  the  sensitive 
areas,  as  practised  in  the  treatment  of  hay  fever.  Sedative  powders  and 
sprays  should  be  used  in  the  intervals  between  the  cauterizations,  which 
should  not  be  made  oftener  than  once  in  five  to  seven  days.  The  cau- 
terizations destroy  the  terminal  fibres  of  the  hypersensitive  nerve,  but 
are  not  deep  enough  to  destroy  the  mucous  membrane. 


CHAPTER  XXXI. 

DISEASES   OF   THE    NASAL   CAVITIES.— Continued. 

RHINITIS.— Continued. 

chronic  rhinitis. — Continued. 

Intumescent  rhinitis,  also  known  as  chronic  catarrh,  and  by  some 
considered  as  one  of  the  forms  of  hypertrophic  rhinitis,  is  the  most 
frequent  of  all  varieties  of  chronic  rhinitis:  it  is  characterized  by  in- 
termittent swelling  of  the  Schneiderian  mucous  membrane,  with  more 
or  less  occlusion  of  the  nasal  passages.  The  swelling  may  involve  both 
cavities  at  once  but  usually  affects  one  side  at  a  time  and  may  change 
in  a  few  moments  to  the  opposite  naris.  This  is  most  noticeable  when 
the  patient  is  lying  upon  the  side,  the  undermost  cavity  being  occluded, 
but  the  swelling  generally  changes  to  the  opposite  naris  within  a  few 
minutes  after  the  patient  turns  over. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membrane  is  usually  congested,  but  is  occasionally  pale,  and  upon  one 
or  both  sides  may  be  swollen.  The  tumefaction  is  most  frequently 
found  over  the  inferior  turbinated  bodies,  but  it  sometimes  involves 
the  middle  turbinals  and  that  part  of  the  septum  directly  opposite. 
Frequently  no  swelling  whatever  is  found  at  the  time  of  examination, 
though  the  history  clearly  shows  that  it  is  present  several  times  during 
the  day  or  night.  The  swelling  interferes  with  nasal  respiration  and 
favors  accumulation  of  secretion  in  the  nasal  arid  post-nasal  cavities, 
consequent  partly  upon  deficient  evaporation,  and  partly  upon  in- 
creased activity  of  the  secreting  glands. 

In  most  cases  the  pharynx,  and  in  many  the  larynx,  finally  becomes 
the  seat  of  chronic  inflammation;  and  in  many  cases  partial  deafness 
results  from  swelling  of  the  mucous  membrane  in  and  at  the  mouth  of 
the  Eustachian  tube.  The  pharyngitis  and  laryngitis,  dependent  in 
part  upon  extension  from  the  nares,  are  chiefly  the  results  of  mouth- 
breathing,  which  becomes  necessary  when  nasal  respiration  is  obstructed. 

Etiology. — The  causes  are  those  of  simple  chronic  rhinitis. 

Symptomatology. — In  most  cases  there  is  a  history  of  unusual  sus- 
ceptibility to  colds  affecting  the  nasal  cavities.  These  attacks  are  most 
common  in  the  spring  and  fall  months,  though  in  some  persons  they 
are  more  frequent  in  winter,  or   occasionally  even  in  warm  weather. 


532  DISEASES  OF  THE  NASAL   CAVITIES. 

After  a  variable  time,  during  which  the  attacks  of  cold  in  the  head  have 
grown  more  and  more  frequent  and  prolonged,  the  affection  finally  be- 
comes fixed  and  the  patient  is  annoyed  much  of  the  time,  especially 
at  night,  by  obstruction  of  nasal  respiration  attended  by  hawking  and 
efforts  to  clear  the  throat,  particularly  in  the  morning  or  after  eating. 
When  tenacious  mucus  adheres  to  the  upper  surface  of  the  palate,  the 
violent  effort  to  dislodge  it  often  causes  vomiting.  Often  the  patients 
are  annoyed  by  slight  hacking  cough,  and  by  frequent  hoarseness,  espe- 
cially on  attempting  to  sing.  By  Eaulin,  of  Marseilles  (Revue  de  laryn- 
gologie,  cV otologic  et  de  rhinologie,  Annual  of  the  Universal  Medical 
Sciences,  1892),  this  is  attributed  to  muscular  fatigue  caused  by  excessive 
vibrations  of  the  vocal  bands  in  an  effort  to  compensate  for  the  loss  of 
resonance  caused  by  the  nasal  obstruction.  In  such  cases  the  voice  has 
often  been  speedily  restored  by  reducing  the  hypertrophies  of  the  septum 
or  turbinated  bodies.  Nevertheless  many  persons  who  suffer  from  all  the 
symptoms  of  nasal  obstruction  become  so  accustomed  to  it  as  scarcely  to 
recognize  the  fact,  and  when  questioned,  affirm  that  they  have  no  ditfi- 
cultv  in  breathing  through  the  nose.  They  claim  to  sleep  well,  and 
assure  the  physician  that  the  throat  is  not  dry  in  the  morning,  that  they 
always  sleep  with  the  mouth  closed,  notwithstanding  the  fact  that 
inspection  shows  the  nares  to  be  more  than  half  closed  by  swelling. 
Many  complain  of  headache  especially  in  the  morning,  of  pains  in  the 
eyes,  of  frequent  hawking  to  clear  the  throat,  or  a  slight  hacking  cough, 
of  dropping  of  mucus  into  the  throat  from  the  naso-pharynx,  and  of 
obstruction  in  the  nares,  especially  upon  taking  cold,  which  they  con- 
tract very  easily. 

The  symptoms  in  mild  cases  usually  disappear  during  the  summer 
months,  or  upon  change  of  climate,  even  though  it  be  but  a  slight 
change.  This  is  peculiarly  noticeable  when  patients  leave  the  vicinity 
of  our  northern  lakes,  especially  in  the  spring  and  early  summer  when 
the  waters  are  icy  or  cold.  In  some  there  may  be  little  difficulty  in 
temperate  weather;  but  in  extremely  cold  or  extremely  warm  weather, 
or  upon  slight  exposure  to  draughts,  or  change -of  temperature  as  in 
going  from  a  warm  to  a  cold  room,  or  the  reverse,  or  even  from  the 
shade  into  the  bright  sunshine,  there  is  a  tendency  to  sneeze,  followed 
by  speedy  closure  of  one  or  both  nares.  I  have  seen  one  patient  suffer- 
ing from  this  form  of  catarrh  who  would  always  sneeze  upon  going  into 
bright  gaslight.  Sometimes  the  inhalation  of  smoke  or  of  odors  from 
certain  plants,  or  drugs,  will  irritate  the  mucous  membrane  and  excite 
excessive  secretion,  with  swelling.  Many  patients  experience  sensations 
of  itching  or  tickling  in  the  mouth,  or  a  feeling  of  dryness,  fulness,  pres- 
sure, or  stuffiness  in  the  nose,  as  the  principal  symptoms.  Often  the 
pharynx  feels  dry  or  uncomfortable,  especially  in  the  morning,  and 
sometimes  obstinate  pricking  or  neuralgic  pains  are  experienced  in  the 
fauces. 

Occasionally  the  patients  are  annoyed  by  repeated  attacks  of  redness 


CHRONIC  RHINITIS.  533 

and  inflammation  of  the  end  of  the  nose.  In  many  instances  the  voice 
is  thick  or  nasal,  and  it  often  becomes  hoarse  from  the  accompanying 
laryngitis,  so  that  patients  are  usually  unable  to  sing  or  shout,  and  easily 
become  fatigued  upon  prolonged  talking.  Such  persons  are  generally 
obliged  to  keep  the  mouth  partially  open  much  of  the  time,  particularly 
when  walking  in  the  wind  or  during  active  exertion,  and  they  are  fre- 
quently in  the  habit  of  yawning  or  taking  deep  respirations  to  make  up 
for  the  constantly  deficient  supply  of  oxygen. 

The  secretions  may  or  may  not  be  increased ;  they  may  be  thin  and 
watery  or  thick  and  tenacious,  or  they  may  dry  into  crusts  which  are  re- 
moved every  two  or  three  days  from  the  nostrils  or  naso-pharynx.  In 
the  nose  these  crusts  are  most  likely  to  collect  upon  the  anterior  part  of 
the  septum,  or  the  anterior  ends  of  the  middle  turbinated  bodies.  Fre- 
quently fine  cobweb-like  shreds  of  mucus  will  be  seen  stretching  from 
the  turbinated  bodies  to  the  sejDtum,  as  in  simple  chronic  catarrh.  If  the 
secretions  collect  and  remain  for  any  length  of  time,  they  become  par- 
tially decomposed  and  offensive,  giving  the  peculiar  catarrhal  odor, 
familiar  even  to  the  laity.  The  tongue  is  commonly  coated  with  a 
white  or  yellowish  fur,  especially  at  its  base,  and  the  digestive  system  is 
so  frequently  disturbed  as  to  lead  to  the  belief  that  in  some  cases  it  is  the 
direct  cause  of  this  disease.  Gaseous  eructations  from  the  stomach,  and 
constipation,  are  frequent  concomitants. 

Upon  inspection,  the  mucous  membrane  is  usually  found  congested, 
though  occasionally  it  may  be  paler  than  normal;  and  one  or  both  nasal 
cavities  are  found  to  be  from  one-third  to  two-thirds  closed  by  swelling 
of  the  inferior  turbinated  bodies.  In  many  cases,  no  swelling  is  ob- 
served at  the  time  of  the  examination;  but  on  the  other  hand  the 
nares  may  be  completely  obstructed.  Swelling  of  the  soft  tissues  over 
the  septum  is  not  infrequently  observed,  especially  running  horizontally 
along  its  upper  half,  and  it  is  not  unusual  to  find  similar  swellings  run- 
ning vertically  from  half  to  two-thirds  the  whole  height  of  the  vomer 
near  its  posterior  border.  The  swollen  membrane  at  the  upper  part  of 
the  septum  is  usually  of  a  slightly  deeper  hue  than  normal;  that  seen 
with  the  rhinoscope  at  the  posterior  border  is  of  a  grayish  color.  The 
posterior  ends  of  the  inferior  or  middle  turbinated  bodies  are  sometimes 
found  much  swollen  and  of  a  grayish  hue;  but  this  is  more  commonly 
present  in  hypertrophic  rhinitis.  By  examination  with  the  probe,  ex- 
quisitely sensitive  spots  are  frequently  detected,  as  in  simple  chronic 
rhinitis.  Whenever  swelling  is  present,  the  soft  tissues  may  be  easily 
pressed  down  until  the  bone  is  felt  beneath,  but  the  dent  thus  formed 
quickly  disappears  as  the  probe  is  removed.  Upon  palpation,  in  this 
way,  the  mucous  membrane  over  the  septum  will  often  be  found  swollen 
two  or  three  millimetres  in  thickness,  and  that  over  the  turbinated 
bodies  from  two  to  five  millimetres.  In  uncomplicated  cases  of  this 
affection,  upon  the  insufflation  of  one  or  two  grains  of  a  four  per  cent  pow- 
der of  cocaine,  or  spraying  the  nares  with  a  weak  solution  of  the  same 


534  DISEASES  OF  THE  NASAL   CAVITIES. 

drug,  the  swelling  will  speedily  subside  aud  the  cavities  appear  of 
normal  size.  Sometimes  this  occurs  spontaneously  during  the  examina- 
tion, from  the  fright  caused  by  suggestions  as  to  the  proper  treatment. 
Sometimes  the  swelling  will  promptly  disappear  upon  exercise,  and  it  is 
not  uncommon  for  patients  to  find  that  they  can  breathe  much  more 
easily  after  going  upstairs,  or  for  them  to  say  that  they  have  to  get  up 
and  walk  about  in  the  night  in  order  to  breathe. 

DIAGNOSIS. — The  affection  is  to  be  distinguished  from  simple  chronic 
rhinitis,  from  hypertrophic  rhinitis  and  from  nasal  mucous  polypi. 

Intumescent  rhinitis  is  differentiated  from  simple  chronic  rhinitis  by 
swelling  of  the  mucous  membrane,  and  the  occurrence  of  frequently  re- 
peated nasal  obstruction. 

It  is  distinguished  from  hypertrophic  rhinitis  by  the  intermittent 
character  of  the  swelling  instead  of  permanent  occlusion  of  the  nares; 
by  the  smooth  surface  of  the  membrane  in  place  of  an  uneven,  nodular 
appearance,  and  by  disappearance  of  the  swelling  under  the  action  of 
cocaine,  which  does  not  affect  true  hypertrophy. 

We  find  that  nasal  mucous  polypi  are  of  lighter  color  and  more 
mobile;  a  probe  may  be  readily  passed  upon  either  side  of  them,  where- 
as it  can  only  be  passed  upon  one  side  of  the  swelling  in  intumescent 
rhinitis,  and.  although  in  the  latter  affection  the  swollen  tissue  may  be 
compressed,  the  enlarged  body  cannot  be  moved  upon  its  base  as  can 
a  polypus.  Again,  cocaine  diminishes  the  swelling  in  intumescent  rhini- 
tis, whereas  it  renders  the  mucous  polypus,  in  most  instances,  more 
prominent  by  diminishing  the  swelling  about  it. 

Prognosis. — If  left  to  itself,  spontaneous  recovery  from  the  disease 
occurs  in  a  few  cases,  but  usually  it  extends  over  months  or  years,  and 
eventually  terminates  in  hypertrophic  rhinitis,  though  occasional  cases 
appear  to  pass  directly  into  the  atrophic  form.  The  frequent  occlusion 
of  the  nares  leads  either  to  pharyngitis  or  laryngitis,  or  both;  in  many 
cases,  throat-deafness  results  from  involvement  of  the  Eustachian  tube, 
the  inflammation  extending  not  infrequently  to  the  middle  ear.  The 
general  health  suffers  from  imperfect  oxygenation  of  the  blood;  and 
although  to  the  casual  observer  the  patients  may  appear  well,  they 
become  easily  fatigued,  are  unable  to  stand  exercise,  and  are  often  sub- 
ject to  illness  upon  slight  exposure.  These  tendencies  may  not  be  rec- 
ognized until  the  marked  improvement  in  the  patient's  general  condi- 
tion, under  appropriate  treatment  of  the  nasal  affection,  demonstrates 
that  they  have  been  present. 

Treatment. — Prophylactic  treatment  is  of  the  greatest  importance 
in  all  persons  predisposed  to  catarrhal  affections.  They  should  avoid 
exposure  to  draughts  or  cold  or  to  undue  heat,  especially  in  badly  ven- 
tilated rooms,  and  so  far  as  possible  the  inhalation  of  air  containing 
irritating  substances.  Woolen  underclothing  should  be  worn  the  year 
round.  The  daily  practice  of  invigorating  exercise,  with  cold  sponging 
of  the  body,  followed  by  vigorous  friction,  and  bathing  the  feet  morn- 


CHRONIC  RHINITIS.  535 

ings  in  cold  water,  are  often  useful  adjuvants  in  the  prevention  of  colds. 
Acute  rhinitis  occurring  in  individuals  thus  predisposed  should  be  cured 
as  speedily  as  possible.  In  all  cases  the  condition  of  the  digestive  or- 
gans should  receive  careful  attention.  In  the  early  stages  the  regular 
use  by  the  patient  of  sedative  remedies,  and  the  occasional  application 
of  mild  astringents  or  stimulants  to  the  nares,  constitute  the  best  means 
for  the  cure  of  the  disease. 

The  milder  stimulating  applications,  which  may  be  made  two  or  three 
times  per  week,  consist  of  aqueous  solutions  of  zinc  sulphate,  carbolic 
acid,  and  zinc  chloride  (Form.  94),  of  sufficient  strength  to  cause  smart- 
ing or  discomfort  for  not  more  than  ten  minutes.  Aqueous  solutions 
may  be  employed  for  home  use  two  or  three  times  daily,  such  as :  boric 
acid  gr.  x.  ad  3  i.,  or  listerine  tt[  xl.  to  lx.  ad  3  i.,  or  sodium  bicarbonate 
and  biborate  aa  gr.  iss.  to  ij.  ad  3  i.,  or  distilled  extract  of  hamamelis 
or  of  pinus  canadensis  ttx  xxx.  to  1.  ad  3  i.  A  saturated  solution  of  boric 
acid  in  camphor  water  is  also  a  useful  soothing  application.  Oily  prep- 
arations such  as  oleum  petrolina  or  liquid  albolene  containing  camphor 
gr.  i.  to  ij.,  menthol  gr.  ss.  to  i.,  oil  of  cloves  t\[  iij.  to  v.,  or  terebene 
HI  viij.  to  xij.  ad  3  i.  (Forms.  105, 106)  are  generally  more  beneficial  than 
the  aqueous  solutions.  The  oleaginous  liquid  alone  may  be  used  as  a 
soothing  application  to  prevent  the  contact  of  irritating  substances  with 
the  mucous  membrane.  In  addition  to  these,  the  sedative  powders  al- 
ready mentioned  in  speaking  of  simple  chronic  rhinitis  (Form.  166) 
may  also  be  employed  once  or  twice  daily  with  benefit  in  certain  cases. 

Cocaine  in  any  quantity  should  never  be  used  continuously,  not 
only  because  of  the  danger  of  forming  the  cocaine  habit,  but  because 
when  used  for  any  length  of  time  it  seems  partially  to  paralyze  the 
vasomotor  nerves,  thereby  causing  turgescence  of  the  cavernous  tissue 
and  thus  increasing  the  difficulty  we  are  trying  to  remove;  but  it  will 
be  found  most  efficient  in  temporarily  removing  swelling  and  relieving 
the  acute  exacerbations  of  this  affection.  Cocaine  is  most  conveniently 
employed  in  powder  (Form.  166),  which  may  be  blown  into  the  ob- 
structed nostril  two  or  three  times  in  twenty-four  hours,  in  quantities 
not  to  exceed  one-thirtieth  of  a  grain  of  cocaine  at  a  dose.  Even  in 
this  quantity  it  should  only  be  used  for  a  few  days,  and  it  is  seldom 
necessary  then  excepting  at  night  or  early  in  the  morning. 

For  the  application  of  powders  to  the  nares,  I  give  patients  a 
short  glass  tube  about  four  millimetres  in  its  internal  diameter  and  four 
inches  in  length,  flattened  and  expanded  at  one  end,  but  round  at  the 
other  (D  B,  Fig.  195). 

A  small  quantity  is  worked  into  the  round  end  by  moving  it  about 
in  the  powder ;  the  end  of  a  piece  of  rubber  tubing  about  nine  inches 
in  length  is  then  slipped  over  the  same  end  of  the  glass  tube;  its 
flattened  end  is  placed  in  the  nostril,  the  other  end  of  the  rubber  tube 
between  the  lips,  and  the  patient  gives  a  short,  quick  puff,  which  blows 
the  powder  into  the  naris.     The  rubber  tube  is  made  of  the  common 


530 


DISEASES  oF  THE  NASAL   CAVITIES. 


drainage  or  nursing-bottle  tubing  with  a  calibre  of  about  three  milli- 
metres. When  the  physician  makes  the  application  himself,  it  is  best 
to  use  a  hand-insufflator  (Fig.  195).  Any  application  which  is  made  as 
often  as  two  or  three  times  a  day  should  not  cause  smarting  or  dis- 
comfort for  more  than  three  to  five  minutes,  and  should  make  the 
patient  subsequently  feel  better,  instead  of  worse;  but  stronger  applica- 
tions, as  already  recommended,  may  be  made  every  two  to  five  days. 
The  sprays  may  be  applied  by  means  of  any  suitable  atomizer.  The 
atomizer  which  I  have  found  most  satisfactory  is  shown  in  Fig.  196. 


Fig.  195.— Powder  Blower.    Three  glass  tubes  03  size).    Straight  tube  for  nasal,  bent  tubes  for 
naso-pharyngeal  or  laryngeal  applications. 

When  secretions  collect  in  large  quantities,  the  patient  should  wash 
the  nose  once  or  twice  daily  with  an  alkaline  solution,  or  with  a  salicy- 
late solution  (Form.  187).  An  excellent  alkaline  solution  may  be  made 
by  dissolving  an  even  teaspoonful  of  sodium  bicarbonate  in  a  half-pint 
of  lukewarm  water,  or  one-half  of  a  teaspoonful  each  of  sodium  bicar- 
bonate and  sodium  chloride  in  the  same  amount  of  water.  In  some  in- 
stances sodium  chloride  alone,  in  the  same  proportion,  seems  to  answer 
a  better  purpose.     This  I  recommend  in  cases  where  the  sodium  bicar- 


La.iOSO*     RUBBC.R    CO, 


Fig.  196.— Davidson's  Oil  Atomizer.  N*o.  50  CV4  size). 


bonate  causes  an  uncomfortable  sensation  of  dryness.  After  the  nose 
has  been  thoroughly  cleansed,  the  applications  already  recommended 
should  be  made.  In  fully  developed  cases  of  intumescent  rhinitis  these 
remedies  will  give  the  patient  temporary  relief,  but  can  seldom  if  ever 
effect  a  cure,  and  they  should  therefore  only  be  employed  as  an  aid  to 
more  radical  treatment,  which  consists  of  the  cauterization  of  the  swollen 


CHRONIC  RHINITIS.  53? 

tissue  either  by  chemical  agents  or  by  the  galvano-cautery;  or  in  the  re- 
moval of  portions  of  the  tissue  with  the  steel-wire  snare.  The  latter  is 
better  suited  to  the  case  of  hypertrophic  rhinitis.  Before  cauterization, 
the  part  should  be  thoroughly  anaesthetized  by  cocaine,  as  recommended 
in  speaking  of  hay  fever. 

Of  the  various  chemical  agents  which  have  been  recommended, 
strong  acetic  or  chromic  acid  is  most  useful,  and  of  these  two  the 
latter  is  more  generally  preferred  by  laryngologists.  It  may  be  em- 
ployed in  solutions  of  fifty  to  seventy-five  per  cent,  or  preferably  a 
small  amount  of  the  acid  may  be  fused  upon  an  aluminium  probe 
(Fig.  197)  and  employed  in  the  solid  form.  I  always  apply  it,  if  at  all, 
in  the  latter  manner,  since  its  effects  can  be  better  controlled,  and  in- 
jury to  other  parts  can  be  more  easily  avoided.  A  few  of  the  crystals 
of  chromic  acid  being  placed  upon  the  end  of  the  flat  aluminium  probe, 
it  is  held  over  the  flame  in  such  position  that  the  acid  slowly  fuses,  and 
then  so  that  it  cools  upon  the  desired  place.  The  fused  acid  is  then 
rubbed  over  the  part  to  be  cauterized,  which  becomes  of  a  brownish  color, 
and  immediately  afterward  an  alkaline  spray  is  thrown  into  the  nostril  to 
neutralize  any  excess  of  acid,  and  to  prevent  it  from  being  diffused  to 


Fig.  19?.— Flat  Nasal  Probe  (2-5  size).    Made  of  aluminium  and  bent  at  an  angle  of  35°. 

other  parts.  The  amount  of  acid  used  at  one  time  should  not  exceed 
four  or  five  times  the  bulk  of  a  pin's  head  or  about  two-thirds  the 
bulk  of  a  flax-seed.  The  acid  should  be  applied  along  a  narrow  strip  of 
membrane  about  three  or  four  millimetres  in  width  and  from  ten  to 
twenty  in  length  according  to  the  depth  of  cauterization,  care  being 
taken  not  to  use  too  much  acid  at  one  time  or  to  cauterize  too  large  a 
surface.  Bosworth  prefers  touching  only  at  separate  points  with  the 
acid,  claiming  that  the  small  eschars,  as  he  expresses  it,  pin  down  the 
mucous  membrane  to  the  bone  beneath;  but  in  my  hands  this  plan  has 
been  less  satisfactory  than  the  one  already  recommended.  I  would 
not  advise  a  repetition  of  cauterization  until  complete  healing  has  oc- 
curred, which  will  require  from  ten  to  twenty  days.  H.  Holbrook  Curtis, 
of  Xew  York,  who  has  had  excellent  results  in  the  treatment  of  this  form 
of  catarrh,  informs  me  that  he  touches  the  lower  half  of  the  inferior 
turbinated  body  along  its  whole  length  with  chromic  acid,  which  he 
commonly  uses  in  strong  solution,  and  repeats  the  cauterization  within 
four  or  five  days. 

Chromic  acid  causes  much  more  pain  than  the  galvano-cautery,  a 
more  irritating  discharge,  and  a  sore  which  heals  more  slowly  than 
that  by  the  latter,  while  its  effects  cannot  be  so  accurately  controlled. 
The  treatment  is  therefore  more  tedious  and  gives  the  patient  much 


538  DISEASES  OF  THE  NASAL  CAVITIES. 

more  discomfort,  and  the  result  is  no  better  than  that  obtained  by  the 
hot  electrode. 

In  using  the  galvano-cautery  I  employ  an  electrode  (No.  2,  Fig.  91), 
with  a  blade  about  fifteen  millimetres  in  length  consisting  of  No.  21 
platinum  wire.  One,  two,  or  more  narrow,  linear  incisions  the  whole 
length  of  the  turbinated  body,  and  deep  enough  to  just  graze  the  bone 
in  two  or  three  places,  should  be  made,  one  at  a  sitting,  with  a  sufficient 
interval  for  healing  to  occur  before  the  cauterization  is  repeated.  These 
lines  are  usually  made  at  the  junction  of  the  middle  with  the  inferior  or 
superior  third  of  the  lower  turbinated  body;  and  in  from  ten  to  fifteen 
days  afterward,  a  similar  cauterization  is  made  upon  the  other  side.  In 
the  same  length  of  time  subsequently  the  first  cauterization  will  have 
healed,  and  if  necessary  the  treatment  may  be  repeated  upon  the  side 
first  treated.  <■ 

Immediately  preceding  or  following  the  cauterization  I  apply  to 
the  nares  a  solution  of  it[  v.  ad  3  i.  of  oil  of  cloves  in  liquid  albolene, 
and  after  the  cauterization  follow  this  by  the  insufflation  of  two  or  three 
grains  of  iodol.  A  light  pledget  of  cotton  is  then  placed  in  the  nos- 
tril, and  the  patient  is  directed  to  wear  this,  changing  it  as  he  wishes, 
for  the  next  forty-eight  hours,  whenever  out  of  doors.  He  is  also  given 
a  four  per  cent  powder  of  cocaine  (Form.  168)  which  he  is  directed  to 
use  three  or  four  times  daily,  providing  the  tissues  swell  so  as  to  occlude 
the  nares.  At  the  end  of  four  or  five  days  he  returns,  and  a  probe  is 
passed  between  the  septum  and  the  turbinated  body  to  prevent  adhe- 
sion; or  if  the  thick  mass  of  exudate,  resembling  false  membrane, 
which  usually  covers  the  wound,  is  still  present,  it  is  gently  removed, 
and  the  line  of  the  cauterization  touched  with  a  ten  grain  solution 
of  silver  nitrate;  or  the  parts  are  simply  sprayed  with  a  stimulating 
solution  of  zinc  sulphate  and  carbolic  acid,  aa  gr.  ij.  ad  3  i.  The  patient 
is  then  given,  to  use  once  or  twice  daily,  instead  of  the  powder  first 
employed,  a  similar  powder  to  which  has  been  added  twenty-five  per 
cent  of  iodol. 

In  most  cases  two  or  three  times  each  day  after  the  cauterization 
the  patient  also  uses  at  home  a  spray  containing  gr.  J  of  thymol, 
gr.  ss.  of  carbolic  acid,  and  Ti[  iij.  of  oil  of  cloves  ad  3  i.  of  liquid  albo- 
lene, or,  if  this  causes  any  irritation,  a  still  milder  application.  Most 
patients  find  this  soothing,  and  it  prevents  the  formation  of  dry  scabs; 
but  for  patients  to  whom  oleaginous  sprays  of  any  form  are  irritating, 
a  spray  of  boric  acid,  gr.  viij.  ad  3  i.,  will  be  found  most  beneficial; 
though  any  of  the  soothing  sprays  already  recommended  may  be  em- 
ployed to  suit  the  indications  of  the  case  or  the  fancy  of  the  patient. 
If  the  soft  tissues  over  the  middle  turbinated  body  or  the  septum  swell, 
they  may  be  treated  in  the  same  manner. 

In  a  few  cases  a  single  cauterization  upon  each  side  will  be  sufficient 
to  effect  a  cure,  and  in  the  great  majority  of  cases  two  cauterizations  uj^on 


CHRONIC  RHINITIS.  53£ 

each  side  are  sufficient;  but  occasionally  three,  four,  or  even  more  will  be 
necessary  before  the  disease  is  checked.  During  the  treatment,  and  for 
a  few  weeks  afterward,  it  is  usually  best  for  the  patient  to  use  some 
of  the  sedative  or  slightly  stimulant  sprays  recommended  for  the 
treatment  of  mild  cases  of  the  disease.  If  the  treatment  is  properly 
carried  out  recovery  may  be  confidently  expected  in  at  least  nineteen 
cases  out  of  twenty.  The  treatment  usually  requires  from  six  to  twelve 
weeks  with  an  average  attendance  at  the  physician's  office  of  about  once 
a  week,  though  many  cases  are  cured  much  more  promptly,  and  rare 
cases  demand  more  extended  treatment. 

In  using  the  galvano-cautery,  I  employ  a  current  sufficiently  strong 
to  heat  the  platinum  wire  to  a  white  heat  within  two  seconds  after 
contact  is  made.  The  electrode  having  been  carried  to  the  back 
part  of  the  tissue  to  be  cauterized,  and  turned  so  that  the  platinum 
wire  rests  against  the  tissue,  the  circuit  is  closed,  and  as  soon  as 
the  sound  of  burning  is  heard,  the  electrode  is  drawn  slowly  forward, 
or,  if  the  bone  is  not  felt,  moved  slightly  backward  and  forward  until 
it  grazes  the  bone,  and  then  drawn  slowly  to  the  anterior  end  of  the 
turbinated  body,  where  it  should  be  lifted  from  the  soft  tissue  before 
the  current  is  turned  off,  and  then  allowed  to  cool'  before  it  is  with- 
drawn from  the  nostril.  If  the  circuit  is  broken  before  the  electrode 
is  lifted  from  the  tissues,  the  eschar  is  pulled  off  with  it  and  bleeding- 
results.  If  the  wire  is  too  hot,  it  cuts  like  a  knife,  and  much  bleeding- 
may  follow;  if  it  is  only  of  a  cherry-red  heat,  or  if  it  is  too  small,  it 
will  cut  through  the  mucous  membrane  too  slowly,  so  that  the  time 
necessary  for  a  sufficiently  deep  cauterization  will  allow  enough  radiation 
of  heat  to  burn  surrounding  tissues. 

Occasionally,  in  spite  of  all  precautions,  adhesions  will  take  place  be- 
tween the  two  walls  of  the  nasal  fossa,  though  this  is  not  apt  to  occur 
except  where  there  is  hypertrophy  of  the  turbinated  bone,  or  an  out- 
growth or  deflection  of  the  septum.  If  adhesions  form,  they  must 
be  cut  or  broken  down,  and  the  parts  kept  apart  by  a  pledget  of  wool 
or  bit  of  rubber  or  gutta-percha  until  healing  occurs.  Sometimes  an 
application  of  monochloracetic  acid  will  prevent  subsequent  adhesions. 

When  patients  find  it  inconvenient  to  call  within  four  or  five  days 
after  the  cauterization,  they  are  directed  to  come  again  at  any  time 
that  suits  their  convenience  after  two  weeks,  and  most  of  them  will 
progress  very  well  in  this  way,  though  there  is  more  liability  to  adhe- 
sion, and  occasionally  the  wound  does  not  heal  as  it  would  if  proper  at- 
tention could  have  been  given  at  an  earlier  date. 

In  a  few  cases  too  much  reaction  will  follow  a  cauterization  of  the  ex- 
tent recommended;  in  these  a  line  only  half  way  across  the  turbinated 
body  should  be  made  at  once.  Usually  the  treatment  causes  little  or 
no  pain,  and  no  subsequent  inconvenience  except  such  as  would  be  ex- 
perienced from  an  acute  cold  in  the  head.     The  discomfort  following 


540  DISEASES  OF  THE  NASAL   CAVITIES. 

the  cauterization  most  frequently  results  from  the  cocaine;  it  may 
often  be  relieved  by  a  cup  of  strong  coffee  or  ten  to  fifteen  grains  of 
potassium  bromide.  Headache  occasionally  follows,  which  is  best  re- 
lieved by  five  or  ten  grain  doses  of  phenacetm,  repeated  in  one,  two, 
or  three  hours  as  needed.  Coexisting  pharyngeal  or  laryngeal  in- 
flammation should  receive  appropriate  treatment  at  the  same  time; 
though  the  physici  ;n  may  with  perfect  candor  assure  his  patient  that, 
as  soon  as  the  nasal  obstruction  is  removed,  at  least  four-fifths  of  the 
difficulty  arising  from  the  other  affection  will  disappear,  and  that  the 
remaining  trouble  will  probably  disappear  within  a  few  months  even 
without  treatment.  In  this  form  of  rhinitis  a  slight  change  of  climate, 
especially  moving  from  the  vicinity  of  large  bodies  of  chilly  water,  will 
often  give  immediate  relief,  though  the  affection  is  liable  to  recur  as 
soon  as  the  patient  returns  to  his  former  abode. 

Hypertrophic  rhinitis  is  a  common  affection,  next  in  frequency 
to  intumescent  rhinitis.  It  is  usually  characterized  by  excessive  dis- 
charge from  the  nostrils  or  into  the  naso-pharynx,  with  hawking  and 
clearing  of  the  throat,  and  more  or  less  permanent  obstruction  of  the 
nares,  though  it  varies  much  from  time  to  time  in  consequence  of  the 
swelling. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membi'ane  is  usually  congested,  but  may  be  paler  than  normal,  and 
hyperplasia  of  the  mucous  and  submucous  tissues  causes  permanent 
thickening  of  the  turbinated  bodies,  especially  the  inferior  (Fig.  198), 
and  sometimes  also  of  the  septum,  usually  at  its  upper  part. 

Occasionally  the  bones  themselves  are  likewise  hypertrophied,  and 
constantly  narrow  the  lumen  of  the  nares.  The  condition  may  be  pres- 
ent upon  one  side  only,  but  commonly  involves  both.  It  is  frequently 
associated  with  deflection  or  exostosis,  or  enchondrosis  of  the  septum, 
in  which  case  the  inferior  turbinated  body  upon  the  concave  side  of  the 
septum  is  apt  to  be  much  more  hypertrophied  than  its  fellow;  indeed, 
the  latter  will  sometimes  be  found  atrophied,  so  that  patients  can 
breathe  more  easily  through  the  side  which  appears  most  obstructed. 
In  addition  to  hypertrophy,  swelling  of  the  soft  parts  is  usually  present, 
so  that  the  nasal  cavity  is  from  one-half  to  two-thirds  closed  or  entirely 
obstructed. 

Etiology. — Hypertrophic  rhinitis  is  usually  preceded  by  frequent 
attacks  of  acute  catarrhal  inflammation,  from  which  intumescent  rhini- 
tis is  at  length  developed,  finally  terminating  in  true  hypertrophy.  It 
is  produced  by  the  same  conditions  that  cause  the  intumescent  form  of 
the  disease. 

Symptomatology. — The  patient  usually  states  that  for  a  long  time 
he  has  taken  cold  easily,  and  for  several  months  or  years  has  been  an- 
noyed by  stopping  up  of  the  nose,  especially  at  night  or  in  the  early 
morning,  and  by  excessive  discharge  from  the  nostrils,  or  into  the  naso- 


CHRONIC  RHINITIS. 


541 


pharynx,  with  hawking  and  clearing  of  the  throat,  or  hoarseness.  More 
recently  one  or  other  naris  has  heen  constantly  obstructed,  so  that  the 
mouth  must  be  kept  open  upon  any  exertion  and  during  sleep.  Fre- 
quently the  sense  of  hearing  is  obtunded;  indeed,  most  cases  of  deaf- 
ness are  the  result  of  hypertrophic  rhinitis.  Frequently  the  general 
health  suffers  in  consequence  of  imperfect  oxygenation  of  blood.  Often 
the  patient  suffers  from  frontal  or  occipital  headache  or  a  feeling 
of  pressure  over  the  bridge  of  the  nose  or  forehead,  and  occasionally 
the  eyes  are  affected  so  that  reading  is  painful  or  impossible,  except  for 


Fig.  198. — Hypertrophy  of  Inferior  Turbinated  Body.  Cross-section  of  head,  froni  frozen 
section,  a,  Middle  turbinated  body:  b,  inferior  turbinated  body  hypertrophied;  c,  superior  turbi- 
nated body ;  d,  sphenoid  cells ;  e,  orifice  of  Eustachian  tube. 


a  few  minutes  at  a  time.  There  is  usually  some  dysphonia  and  dysp- 
noea, the  mucous  membrane,  especially  over  the  inferior  turbinated 
bod}",  is  thickened,  and  its  surface  is  usually  more  or  less  uneven  in  ap- 
pearance, sometimes  presenting  distinct  nodules.  The  amount  of  swell- 
ing varies  much  from  time  to  time,  and  it  may  be  uniform  over  the  whole 
turbinated  body  or  limited  to  portions  of  it.  Thus,  it  is  common  to 
find  either  the  anterior,  middle,  or  posterior  portion  of  the  cavity  most 
occluded  ;  or  along  the  upper  portion  of  the  turbinated  bodies  there 
maybe  but  little  thickening  while  the  lower  portion  touches  the  septum, 
the  inferior  border  resting  upon  the  floor  of  the  nares.     Whenever  the 


542  DISEASES  OF  THE  NASAL   CAVITIES. 

mucous  membrane  of  the  two  sides  of  the  nasal  cavity  is  in  con- 
tact, we  usually  find  a  considerable  collection  of  mucus  or  muco-pus  at 
the  lower  portion  of  the  fossa.  In  many  cases  cobweb-like  shreds  of 
mucus  will  be  found  extending  from  side  to  side  as  in  other  forms  of 
rhinitis  already  discussed,  or  the  dried  secretions  may  have  collected  in 
crusts  upon  the  cartilaginous  septum,  or  about  the  middle  turbinated 
body.  Usually  the  vault  of  the  pharynx  is  congested,  and  contains 
tenacious  mucus  or  dried  masses,  and  the  posterior  ends  of  the  inferior 
or  middle  turbinated  bodies  are  enlarged  (Fig.  199).  These  commonly 
appear  in  the  rhinoscope  of  a  gray  color,  but  occasionally  of  darker  hue, 
even  purple,  and  the  surface  has  a  nodular  or  raspberry-like  appearance. 
The  posterior  ends  of  the  turbinated  bodies  of  both  sides  may  be  so 
enlarged  as  to  project  into  the  naso-pharynx,  and  may  even  come  into 
contact  behind  the  septum,  nearly  or  quite  occluding  the  choana?. 
The  middle  turbinated  bodies  are  much  less  frequently  hypertrophied 


Fig.  199.— Hypertrophy  op  Posterior  Ends  of  Inferior  Turbinated  Bodies. 

than  the  inferior,  but  when  enlarged  they  press  against  the  septum, 
frequently  causing  neuralgic  pains  in  the  forehead  and  eyes,  and  sensa- 
tions of  pressure  on  the  bridge  of  the  nose.  Occasionally  the  middle 
turbinated  bodies  are  found  hypertrophied,  while  the  inferior  are  normal 
in  size  or  perhaps  atrophied. 

Hypertrophy  of  the  soft  tissues  upon  the  septum  in  the  majority  of 
cases  is  found  at  its  middle  or  upper  third,  running  nearly  horizontally, 
or  extending  vertically  near  the  posterior  edge  of  the  vomer. 

Diagnosis. — Unless  the  parts  are  carefully  examined,  the  affection 
is  apt  to  be  confounded  with  any  of  the  other  causes  of  nasal  obstruc- 
tion; but  by  a  consideration  of  the  history,  and  a  careful  inspection  and 
palpation  of  the  parts,  it  may  be  easily  distinguished  from  all  diseases 
except  intumescent  rhinitis  and  syphilitic  affections  of  the  nose. 

The  tissues  are  easily  impressed  with  the  probe  in  intumescent  /■hi /li- 
tis, and  swelling  rapidly  and  completely  disappears  on  application  of 
cocaine,  signs  not  obtained  in  true  hypertrophy. 

It  is  impossible  to  distinguish  hypertrophic  rhinitis  from  syphilitic 
disease  of  the  nose,  attended  simply  by  persistent  swelling  without  ulcer- 
ation, except  by  careful  consideration  of  the  history  and  watching  re- 


CHRONIC  RHINITIS.  543 

suits  of  specific  treatment.  It  is  often  difficult  to  get  the  specific  his- 
tory of  syphilitic  patients,  for  reasons  already  indicated. 

Excessive  hypertrophy  of  the  anterior  or  posterior  end  of  the  tur- 
binated bodies  is  distinguished  from  mucous  polypi  by  inspection,  and 
joalpation  with  the  probe,  which  can  be  passed  between  a  polypus  and 
the  external  wall,  but  cannot  be  so  manipulated  in  hypertrophy.  The 
posterior  end  of  the  turbinated  body  when  hypertrophied  has  much  the 
color  of  a  mucous  polypus,  but  its  surface,  unlike  that  of  a  polypus, 
is  uneven  and  slightly  nodular,  and  it  is  usually  of  a  deeper  hue  and 
has  not  the  translucent  appearance  of  the  polypus. 

Prognosis. — Hypertrophic  rhinitis  left  to  itself  may  extend  over  a 
period  of  several  years.  I  have  known  of  no  case  terminating  in  less 
than  one  year,  but  have  seen  one  well-marked  case  where  the  affec- 
tion merged  into  atrophic  rhinitis  within  eighteen  months.  In  many 
instances  the  hypertrophy  gradually  increases  or,  after  a  certain  point 
has  been  reached,  appears  to  remain  without  change;  but  in  a  considera- 
ble number  of  cases,  atrophy  finally  begins  and  continues  until  the 
secretions  become  much  altered,  and  the  cavities  greatly  enlarged  and 
more  or  less  obstructed  by  decaying  mucus  and  muco-pus,  which  cause 
the  offensive  odor  of  ozasna.  In  more  favorable  cases,  atrophy  continues 
for  a  time  until  the  nasal  cavities  once  more  become  free,  and  then  ceases, 
whereby  spontaneous  recovery  results.  There  is  a  common  belief  with 
the  laity,  and  among  physicians  who  have  been  in  practice  for  more 
than  ten  or  fifteen  years,  that  little  or  nothing  can  be  done  for  chronic 
catarrh  by  treatment;  and  this  belief  was  well  founded  until  the  advent 
of  the  improved  methods  of  treatment  in  vogue  during  the  last  decade. 

Although  the  general  health  is  often  somewhat  impaired  by  this 
affection,  there  is  little  or  no  evidence  that  it  ever  terminates  in  tuber- 
culosis. It  is  true  that  patients  suffering  from  chronic  catarrh  fre- 
quently die  of  tuberculosis,  but  apparently  no  more  frequently  than 
those  free  from  the  nasal  disease.  On  theoretical  grounds,  it  would  ap- 
pear that  obstruction  of  the  nares,  by  interfering  with  free  expansion 
of  the  lungs,  would  sooner  or  later  cause  collapse  of  some  of  the  air 
cells,  with  a  consequent  chronic  inflammation  and  finally  tuberculosis. 
I  have  seen  some  cases  which  seem  to  substantiate  this  hypothesis. 

Treatment. — Various  medicinal  substances  have  been  recommended 
internally  and  locally  for  the  cure  of  hypertrophic  rhinitis,  but  none  of 
them  are  of  much  value  excepting  when  used  in  connection  with  proper 
surgical  measures;  and  a  cure  can  seldom  be  effected  except  by  the  re- 
moval of  some  portion  of  the  redundant  tissue.  This  may  be  accom- 
plished by  means  of  chemical  caustics,  the  galvano-cautery,  burrs,  tre- 
phines, scissors,  saws,  or  the  snare.  Among  the  chemical  agents  which 
have  been  recommended  are  the  mineral  acids,  especially  nitric  and 
sulphuric,  solution  of  mercury  nitrate,  London  paste,  glacial  acetic,  and 
chromic  acid;  all  of  these  have  passed  into  general  disuse  excepting 


544  DISEASES  OF  THE  NASAL   CAVITIES. 

acetic  and  chromic  acid.  The  former,  especially,  in  the  form  of  mono- 
chloracetic  acid,  is  useful  particularly  in  cases  where  there  is  liability  to 
adhesion  of  the  opposing  surfaces  after  cauterization,  and  either  this 
or  the  glacial  acetic  acid  may  be  used  to  reduce  hypertrophy  of  the 
soft  tissues,  but  they  are  less  efficient  than  chromic  acid,  which,  though 
an  effectual  remedy,  is  open  to  the  objections  mentioned  under  intumes- 
cent  rhinitis. 

Injections  of  carbolic  acid,  beneath  the  mucous  membrane,  by  means 
of  a  hypodermic  syringe,  have  been  recommended,  and  the  treatment 
appears  to  have  been  successful  in  some  instances. 

The  majority  of  cases  may  be  cured  by  cauterization  as  already  de- 
scribed in  the  treatment  of  intumescent  rhinitis.  I  prefer  the  galvano- 
cautery  for  most  cases,  and  make  linear  incisions,  as  already  recommended, 
two.  three,  or  more  of  which  may  be  necessary  upon  the  inferior  and 
possibly  the  middle  turbinated  bodies  of  each  side.  In  cauterization 
of  the  middle  turbinated  body,  I  frequently  use  a  small  loop-like  or 
pointed  electrode  (Xo.  3  or  4,  Fig.  91),  which  is  thrust  into  the  lower 
edge  of  the  turbinal  in  three  or  four  places.  In  cauterizing  the  inferior 
turbinated  body  I  sometimes  use  the  same  lance-pointed,  slender  elec- 
trode, and  carry  it  all  the  way  from  before  backward  beneath  the  mucous 
membrane  without  burning  through  to  the  surface  except  at  the  points 
of  entrance  and  exit.  In  seventy-five  per  cent  of  cases,  not  more  than 
two  lines  are  necessary  upon  either  turbinated  body,  and  in  only  five  or 
ten  per  cent  will  more  than  three  be  needed.  When  the  middle  turbi- 
nal is  involved,  generally  one  or  two  cauterizations  are  all  that  will  be 
useful,  and  if  they  do  not  succeed,  some  portion  of  the  bone  must  be 
removed. 

In  hypertrophic  rhinitis,  Harrison  Allen  has  recommended  press- 
ing the  incandescent  loop  of  the  galvano-cautery  into  the  tissue  and 
drawing  it  forward  until  a  small  piece  has  been  scooped  out  by 
the  burning  wire.  In  some  cases,  especially  in  hypertrophy  of  the 
middle  turbinated  body,  when  the  soft  tissue  stands  out  prominently 
it  may  be  caught  and  removed  by  the  galvano-cautery  ecraseur. 
particularly  where  there  is  objection  to  the  bleeding  which  would 
follow  removal  by  the  cold  steel  wire.  When  there  is  great  hyper- 
trophy of  the  soft  tissues,  it  is  far  better  to  remove  the  redundancy  by 
the  scissors  or  snare.  Sometimes  with  the  nasal  scissors  (Fig.  200)  I  cut 
off  the  lower  edge  of  the  inferior  turbinated  body,  but  I  prefer  the 
snare  where  the  wire  can  be  made  to  hold.  As  a  rule,  in  all  these  opera- 
tions the  parts  should  first  be  thoroughly  anaesthetized  by  cocaine,  but 
sometimes  the  swelling  is  so  reduced  by  this  agent  that  the  snare  cannot 
be  made  to  hold,  whereas  the  redundant  tissue  could  be  easily  secured 
before  the  cocaine  had  been  applied.  In  such  cases  it  is  sometimes  best  to 
introduce  and  tighten  the  snare  first  and  subsequently  to  apply  cocaine. 
In  those  patients  who  can  easily  endure  pain  the  snare  may  be  used  with- 


CHRONIC  RHINITIS.  5+5 

out  cocaine,  being  gradually  tightened  until  it  causes  the  patient  to 
wince;  then  after  resting  two  or  three  minutes  it  is  tightened  still  more 
until  it  again  causes  pain,  when  another  rest  is  taken;  this  process  is 
continued  until  the  mass  is  cut  off.  This  slow  process  has  the  advan- 
tage of  causing  a  minimum  amount  of  bleeding.  In  hypertrophy  of 
the  anterior  end  of  the  turbinated  body,  if  the  snare  cannot  be  made  to 
hold  alone,  the  tissue  may  be  transfixed  with  a  needle,  as  recommended 
by  Jarvis,  of  New  York,  the  wire  being  slipped  over  the  end  of  the  nee- 
dle and  tightened  down  behind  it. 

In  posterior  hypertrophy  the  snare  should  be  armed  with  a  No.  5 
steel  jnano-wire;  the  loop,  of  proper  size,  should  be  bent  sharply  over 
the  end  of  the  canula,  as  recommended  by  Bosworth;  and  then  drawn 
slightly  into  the  canula  to  straighten  it  during  introduction  into  the 
naris.  When  it  has  been  passed  to  the  back  part,  the  wire  is  again 
crowded  forward  until  the  bend  is  brought  to  the  end  of  the  canula, 
when  it  springs  outward,  and  may  be  made  to  engage  the  diseased  mass. 


Fig.  800.— Ingals1  Nasal  Scissors  (^size). 

The  end  of  the  snare  should  then  be  pressed  firmly  against  the  tur- 
binated tissue,  the  wire  drawn  taut,  and  subsequently  gradually  tight- 
ened by  the  milled  wheel.  When  this  method  is  practicable,  it  is  to 
be  preferred  to  the  slower  process  of  cauterization,  for  by  it  a  large 
amount  of  the  redundant  mass  is  at  once  removed,  and  the  reaction 
which  follows,  as  well  as  the  consequent  discomfort  to  the  patient,  is 
much  less  than  after  cauterization. 

When  any  operation  liable  to  be  followed  by  much,  bleeding  is 
done,  the  naris  should  be  tamponed  with  lint  or  gauze,  as  recom- 
mended in  speaking  of  epistaxis  and  the  operation  for  exostosis. 
Even  in  cases  where  the  snare  or  the  scissors  are  applicable,  it  is 
usually  also  necessary  to  cauterize.  It  will  be  seen  that  the  treat- 
ment of  this  affection  is  essentially  the  same  as  that  of  the  intumes- 
cent  variety  of  rhinitis,  except  that  here  we  desire  to  remove  redund- 
ant tissue,  while  in  simple  swelling  we  aim  to  destroy  as  little  tissue 
as  possible.  In  both  instances  it  should  be  the  effort  of  the  physician 
to  save  as  much  mucous  membrane  as  would  normally  cover  the  farts,  and 
to  form  as  little  cicatricial  tissue  as  possible.  In  a  considerable  number 
of  eases  of  hypertrophic  rhinitis  the  bones  are  also  enlarged  so  much 
35 


546 


DISEASES   OF  THE  NASAL   CAVITIES. 


that  no  treatment  of  the  soft  tissue  can  sufficiently  remove  the  obstruc- 
tion. In  these  the  bony  tissue  may  be  removed  with  saw  and  scissors, 
or  better  with  the  dental  burr  (Fig.  201)  or  the  nasal  trephine  (Fig.  202). 
These  instruments,  attached  to  the  electric  motor  or  dental  engine,  are 
run  beneath  the  mucous  membrane,  enough  of  the  bone  being  removed 
to  allow  the  soft  tissue  to  contract  until  sufficient  space  is  obtained. 
Between  the  operations  the  same  sedative  or  slightly  stimulating 
powders  and  sprays  should  be  employed  that    were  recommended  for 


treatment  of  intumescent  rhinitis.  If  adhesions  of  the  opposing  sur- 
faces occur,  they  must  be  broken  down  or  cut  with  scissors,  and  the 
surfaces  kept  apart  by  gutta-percha,  or  a  rubber  plug,  or  by  a  pledget 
of  wool,  until  healing  occurs.  The  wool  is  much  better  than  cotton,  as 
it  becomes  larger  when  moistened  by  the  secretion,  whereas  the  cotton 
plug  becomes  smaller.  Sometimes  by  cauterizing  the  raw  surface  with 
monochloracetic  acid,  which  has  the  property  of  forming  an  eschar  that 
usually  remains  until  healing  has  taken  place  beneath,  subsequent  ad- 
hesions of  the  part  may  be  prevented.  Where  a  spur  of  cartilaginous  or 
bony  tissue  projects  from  the  septum,  it  is  usually  necessary  to  remove 
it  before  the  hypertrophied  turbinated  bodies  can  be  satisfactorily  treated; 
otherwise  adhesions  are  very  apt  to  take  place. 

Metallic,  gutta-percha,  or  soft-rubber  tubes,  sponge  and  laminaria 
tents,  have  also  been  recommended  for  the  cure  of  hypertrophic  rhinitis. 


Fig.  202.— Nasal  Trephines  (actual  size).    Modification  of  Curtis. 

When  tents  are  used  which  swell  by  absorbing  moisture,  they  should  be 
allowed  to  remain  for  only  a  short  time,  and  should  be  moved  slightly 
back  and  forth  frequently  as  the  swelling  progresses,  to  prevent  them 
from  becoming  fixed  too  firmly  in  the  cavity.  Tubes  may  be  introduced 
and  worn  for  several  hours  at  a  time,  providing  they  do  not  cause  too 
much  pain;  theoretically,  this  procedure  is  excellent,  but  practically  a 
tube  large  enough  to  affect  all  gf  the  diseased  tissue  can  seldom  be  in- 
troduced into  the  nostril.  Furthermore,  in  the  majority  of  cases  the 
nares  are  so  sensitive  that  tubes  cannot  be  tolerated;  therefore,  this 
form  of  treatment  has  been  abandoned  except  for  some  special  cases. 


CHRONIC  RHINITIS.  547 

Whatever  treatment  is  adopted,  the  cavity  should,  not  be  made  larger 
than  normal.  Frequently  patients  will  urge  the  physician  to  make  it 
so  large  that  they  will  never  be  troubled  again,  even  upon  taking  cold; 
but  this  procedure  is  injudicious,  and  would  subsequently  be  regretted 
by  both  patient  and  physician;  for  if  the  calibre  is  greater  than  normal, 
secretions  are  liable  to  collect,  decompose,  and  give  offeiisive  odors,  as  in 
atrophic  rhinitis.  It  is  better  to  do  too  little  than  too  much;  but  the 
patient  should  not  be  kept  under  treatment  while  we  are  accomplishing 
nothing.  The  physician  must  not  be  contented  with  making  soothing 
applications  which  give  but  temporary  relief.  These  can  be  made  quite 
as  well  by  the  patient,  and  if  for  any  reason  the  soothing  form  of  treat- 
ment seems  best,  we  are  to  remember  that  no  good  will  result  by  seeing 
the  patient  of  tener  than  once  or  twice  in  a  month. 

Submucous  infiltration  of  the  sides  of  the  vomer  is  common 
in  chronic  rhinitis,  especially  in  the  hyper- 
trophic variety;  it  is  characterized  by  more  or 
less  difficulty  in  nasal  respiration  and  increased 
secretion.  It  is  often  associated  with  chronic  in- 
flammation of  the  pharyngeal  mucous  membrane, 
and  sometimes  with  adenoma  of  the  vault  of  the 
pharynx.  The  altered  mucus  collects  in  the 
posterior  nares  and  drops  into  the  throat  or  causes 

r  .  |  Fig.  203.— Submucous  In- 

frequent  hawking.      I  he  symptoms  are  those  of    filtration    at   sides  of 
post-nasal  catarrh.     Inspection  by  the  aid  of  the    VoMER  (Cohen). 
rhinoscope  reveals  a  yellowish  white  or  gray  puffiness  on  one  or  both 
sides  of  the  vomer,  near  its  posterior  margin  (Fig.  203). 

Diagnosis. — There  can  be  no  difficulty  in  the  diagnosis  when  pharyn- 
geal affections  have  been  excluded  and  the  characteristic  appearances 
just  mentioned  are  discovered. 

Treatment. — We  should  contract  or  destroy  the  cedematous  tissue 
by  means  of  the  galvano-cautery,  or  we  may  tear  it  off  with  forceps. 
The  former  is  most  effective.     Astringents  have  little  effect. 

Atrophic  rhinitis  is  a  chronic  inflammation  of  the  nasal  mucous 
membrane,  characterized  by  abnormal  enlargement  of  the  cavities, 
and  the  collection  within  them  of  drying  secretions,  giving  rise  some- 
times to  an  extremely  offensive  odor.  It  occurs  in  all  countries  and 
among  all  classes,  but  is  most  frequently  found  in  children  or  young 
adults,  and  according  to  Greville  McDonald  (Diseases  of  the  isose) 
is  most  common  in  girls.  I  have  never  observed  it  in  children  under 
eight  years  of  age  nor  in  adults  over  forty;  most  cases  occur  before  the 
twenty-fifth  year,  very  few  being  observed  in  patients  more  than 
thirty-five  years  of  age. 

Anatomical  and  Pathological  Characteristics. — The  nasal 
cavities  are  widened,  even  to  two  or  three  times  their  normal  size,  the 
turbinated  bodies  appear  smaller  than  normal,  and  in  advanced  cases 


548  DISEASES  OF  THE  NASAL  CAVITIES. 

they  may  have  entirely  disappeared.  It  is  not  unusual  to  find  the  in- 
ferior turbinated  bodies  much  smaller  than  normal,  while  the  middle 
turbinals  are  still  hypertrophied.  As  a  result  of  changes  in  the  mucous 
membrane,  involving  its  blood  vessels  and  glands,  the  secretion  be- 
comes tenacious  and  of  a  muco-purulent  character;  and  in  consequence 
of  the  large  size  of  the  nasal  cavities  it  is  impossible  for  the  patient  to 
secure  a  sufficient  blast  of  air  for  its  expulsion;  therefore  it  dries  upon 
the  surface,  partially  decomposes,  and  thus  forms  crusts  which  may 
completely  block  the  cavities.  These  crusts  are  finally  separated  by  the 
increased  secretion  beneath  them  and  may  then  be  expelled,  but  only  to 
be  soon  replaced  by  others  of  the  same  character. 

The  pathology  of  the  disease  is  still  a  mooted  question,  and  it  would 
be  profitless  for  us  to  enter  into  the  controversy.  I  favor  the  theory 
that  in  most  cases  the  atrophy  is  the  result  of  previous  hypertrophy. 
The  mucous  membrane  is  usually  anaemic,  but  seldom  if  ever  ulcerated, 
excepting  that  in  some  instances  abrasion  of  the  septum  may  have  been 
caused  by  picking  the  nose. 

Etiology. — The  cause  cannot  always  be  ascertained,  but  in  some 
persons  a  history  of  frequent  colds,  with  more  or  less  complete  obstruc- 
tion of  the  nares  for  a  considerable  period,  sometimes  dating  from  an 
exanthematous  fever,  and  at  others  from  an  injury,  leads  to  the  belief 
that  the  affection  is  usually  preceded  by  chronic  catarrhal  inflammation, 
and  favors  the  theory  that  atrophy  results  from  an  antecedent  hyper- 
trophy. 

Symptomatology. — The  patient  is  usually  in  good  health  at  the 
beginning,  but  commonly  the  general  condition  suffers  with  the  advance 
of  the  disease.  Usually  the  nose  is  broad,  the  ala?  thick,  the  lips 
thickened  and  prominent,  and  the  whole  physiognomy  is  lacking  in  ex- 
pression, as  is  often  seen  in  the  strumous  diathesis.  The  eyes  are 
often  affected,  the  sense  of  smell  is  usually  lost,  and  partial  deaf- 
ness commonly  exists.  The  secretion,  which  is  of  a  muco-purulent 
character  is  tenacious,  and  usually  there  is  but  little  discharge  from 
the  nose  except  at  intervals  of  once  or  twice  a  week,  when  the  crusts 
formed  by  drying  of  the  secretion  are  expelled.  The  breath  has  an 
exceedingly  offensive  odor  caused  by  decomposition  of  the  retained 
secretion.  So  great  indeed  is  this  that  it  will  often  speedily  permeate 
a  whole  room,  though,  perhaps  fortunately  for  the  pttimt  the  sense,  of 
smell  is  usually  lost,  so  that  he  is  spared  much  personal  discomfort.  The 
foulness  of  this  indescribable  odor  is  only  second  to  that  of  syphilitic 
necrosis  of  the  nasal  bones,  and  is  so  peculiar  that,  when  once  detected, 
it  becomes  a  valuable  diagnostic  symptom. 

Upon  inspection  of  the  nares,  we  are  at  once  impressed  with  the 
abnormal  size  of  the  cavities,  unless  they  be  choked  by  dried  secre- 
tions. "When  the  crusts  are  removed,  Ave  observe  the  small  size,  or 
absence,  of  some  or  all  of  the  turbinated  bodies,  with  perhaps  hyper- 
trophy of   others,  and  find    that  usually  we  may  easily  see  the   naso- 


CHRONIC  RHINITIS.  549 

pharynx  and  often  the  orifice  of  the  Eustachian  tube  through  the 
nostril.  The  secretion  which  has  remained  longest  in  the  nose  is  of 
a  brownish  or  blackish  color;  that  less  old,  of  a  yellowish  or  greenish 
hue.  In  most  cases  where  crusts  are  found  upon  the  surface,  atrojmy 
of  the  mucous  membrane  is  very  apparent,  and  the  odor  is  offensive. 
In  some  cases  the  secretion  is  thin,  of  a  purulent  character,  and  may 
be  easily  washed  away,  even  though  the  patient  cannot  expel  it  by 
blowing  the  nose.  Immediately  after  washing  the  nares  the  mucous 
membrane  may  appear  redder  than  normal,  as  the  result  of  the  cleans- 
ing process,  though  it  is  commonly  anaemic. 

Diagnosis. — The  affection  is  liable  to  be  mistaken  for  lupus,  syph- 
ilitic disease  of  the  nose,  suppuration  of  the  accessory  cavities,  and  rhino- 
liths  or  foreign  bodies  in  the  nose.  There  is  usually  no  difficulty  in 
distinguishing  it  from  lupus,  because  of  the.  external  manifestations 
of  the  latter  disease;  but  in  lupus  vulgaris,  crusts  and  scabs  similar  to 
those  found  in  atrophic  rhinitis  are  formed;  these  are  usually  closely 
adherent  to  the  septum  instead  of  the  turbinals;  and  unlike  the  crusts 
in  atrophic  rhinitis  when  removed,  they  leave  an  ulcerated  surface  which 
usually  bleeds  and  is  marked  in  one  or  more  places  by  the  typical 
lupus  tubercle. 

On  account  of  the  offensive  odor,  syphilitic  disease  of  the  nose  is  espe- 
cially liable  to  be  mistaken  for  atrophic  rhinitis;  but  in  syphilis,  upon 
examination  with  a  probe,  dead  bone  is  often  detected,  and  upon  cleans- 
ing the  part,  ulceration  or  perforation  of  the  septum  or  hard  palate 
is  apt  to  be  found ;  at  the  same  time  there  may  be  falling  in  of  the 
bridge  of  the  nose,  which  does  not  occur  in  simple  atrophy. 

An  offensive  odor  arises  from  suppuration  of  tl?e  accessory  cavities,  but 
unlike  atrophic  rhinitis  this  is  almost  always  unilateral;  the  correspond- 
ing naris  is  not  likely  to  be  enlarged,  and  the  sense  of  smell  is  seldom 
lost;  therefore  the  patient  can  generally  appreciate  the  odor  sooner  than 
those  about  him. 

An  offensive  odor,  with  profuse  discharge  from  one  side,  arises 
from  rhinoliths  or  foreign  bodies  in  the  nose;  but  after  the  parts  are 
cleansed,  offending  bodies  may  be  readily  detected  by  inspection  or 
palpation  with  the  probe. 

Prognosis. — If  left  to  itself,  atrophic  rhinitis  continues  for  many 
years;  but  it  is  seldom  observed  after  the  thirty-fifth  year. '  As  the  history 
shows  that  even  with  the  most  indifferent  care  most  patients  eventually 
get  well,  it  is  probable  that  there  is  a  spontaneous  tendency  to  recovery 
about  middle  life.  Under  appropriate  treatment,  most  cases  may  be 
cured  within  from  six  to  twenty-four  months,  if  the  patient  will  give  it 
proper  attention.  In  nearly  every  case  the  offensive  odor  may  be  speedily 
relieved,  and  it  will  not  reappear  if  perfect  cleanliness  is  observed.  We 
cannot  hope,  however,  to  cure  the  anosmia,  and  the  deafness  associated 
with  atrophic  rhinitis  is  seldom  remediable.     Eestoration  of  the  atro- 


550 


DISEASES  OF  THE  NASAL   CAVITIES. 


phied  structures  can  seldom  be  expected,  though  I  have  seen  a  few  cases 
in  which  undoubted  atrophy,  with  great  enlargement  of  the  nasal  cavi- 
ties, has  so  far  disappeared  as  a  result  of  treatment,  that  the  nares  be- 
came of  normal  size,  and  in  one  case  even  smaller  than  desirable.  There- 
fore I  agree  with  Moure,  of  Bordeaux,  who  holds  out  hope  of  regeneration 
of  atrophied  structures  in  some  cases.  Impairment  of  the  general 
health  resulting  from  constant  inhalation  of  the  fetid  air  from  the  nose, 
and  probably  from  partial  absorption  of  the  secretion  is  speedily  remedied 
as  the  local  disease  is  relieved. 

Teeatment. — Judging  from  the  great  importance  attached  by  vari- 
ous authors  to  special  forms  of  local  treatment  it  is  probably  of  little 
consequence  what  remedies  we  employ,  so  that  they  be  used  in  such 
manner  as  to  keep  the  nares  cleansed  and  disinfected,  and  the  mucous 
membrane  slightly  stimulated.  Cleanliness  must  be  insisted  upon, 
otherwise  any  form  of  treatment  will  be  of  little  avail.  It  is  maintained 
by  some  that  this  cleansing  must  be  done  by  the  physician,  to  which 
there  is  no  objection,  providing  he  has  sufficient  time  and  it  does  not 
entail  too  much  expense  upon  the  patient;  but  it  is  entirely  unnecessary 


Fig.  204.—  Ingals'  Nasal  Syringe  (^  size). 

for  the  physician  to  perform  these  ablutions  if  he  will  insist  that  the 
patient  do  it  himself.  The  patient  should  be  directed  to  wash  the 
nose  thoroughly  two,  three,  or  four  times  daily,  using  from  half  to 
one  and  a  half  pints  of  fluid  each  time,  as  may  be  found  necessary  to 
accomplish  the  object.  In  some  cases  it  is  sufficient  for  the  patient  to 
snuff  fluid  through  the  nose  from  the  palm  of  the  hand.  In  others  it  is 
better  to  use  some  form  of  nasal  syringe  (Fig.  204)  or  the  nasal  douche, 
though  the  latter  should  be  avoided  if  possible,  on  account  of  the  danger 
of  causing  deafness  by  forcing  fluids  through  the  Eustachian  tubes  to 
the  middle  ear.  In  using  any  form  of  nasal  syringe  or  douche,  but  little 
force  should  be  employed,  the  mouth  should  be  kept  open,  and  the 
patient  must  be  careful  not  to  swallow  during  the  washing  process.  As 
a  rule,  the  solution  should  be  warm,  though  with  some  patients  the 
stimulation  of  cold  douches  answers  an  excellent  purpose.  Pure  water 
is  sometimes  sufficient,  though  usually  it  is  better  to  use  solutions  of 
some  of  the  sodium  salts,  of  which  sodium  chloride  or  bicarbonate,  or 
the  salicylate  mixture  (Form.  187)  may  be  employed  in  the  proportion 


CHRONIC  RHINITIS. 


551 


of  a  heaping  teaspoonful  to  a  pint  of  hike-warm  water.  Sea  salt  may 
be  used  in  place  of  the  common  article,  but  is  no  better.  Carbolic  acid, 
listerine,  or  other  antiseptics  in  small  quantity  may  be  added  to  this 
solution  if  desired.  After  the  part  is  thoroughly  cleansed,  various  reme- 
dial agents  may  be  employed,  the  object  being  to  slightly  stimulate  the 
mucous  membrane  with  the  hope  of  improving  its  nutrition,  increasing 
the  glandular  secretion,  and  preventing  suppuration  and  decomposition. 
For  the  latter  purpose  iodoform  is  an  excellent  agent,  though  too  offen- 
sive for  use  in  private  practice. 

In  hospital  and  dispensary  work  no  remedy  has  given  me  more  satis- 
faction in  atrophic  rhinitis  than  a  powder  consisting  of  equal  parts  of 
iodoform  and  boric  acid,  which  is  thrown  freely  into  the  nasal  cavities 
two  or  three  times  a  week,  after  the  parts  have  been  cleansed  by  the 
patient  as  directed.     In  private  practice,  europhen  or  iodol  may  take 


Sharp  &*  Smith. 


Fig.  205.— Nasal  Douche. 


Fig.  206.— Travelers'  Nasal  Douche. 


the  place  of  iodoform.  I  use  the  latter  much  alone,  and  also  variously 
combined  with  mercury  bichloride,  myrrh,  gum  benzoin,  berberine, 
boric  acid,  aristol,  and  cocaine,  with  sugar  of  milk  as  a  base  (Form.  170 
to  172  and  181). 

Powders  are  used  when  there  is  free  secretion,  and  sometimes, 
even  though  there  is  much  dryness  of  the  part,  they  have  a  most  satis- 
factory effect,  especially  if  associated  with  the  oleaginous  sprays  of  car- 
bolic acid,  menthol,  oil  of  cloves,  or  other  similar  substances  in  liquid 
albolene;  the  rule  being  that  whatever  application  is  made  should  not 
cause  the  patient  discomfort  for  more  than  five  or  ten  minutes.  The 
powders  and  sprays  I  generally  give  in  the  following  strength,  to  be 
used  by  the  patient  two  or  three  times  daily:  mercury  bichloride, 
from  one-tenth  to  one-fifth  of  one  per  cent;  iodol,  twenty-five  per  cent; 
boric  acid,  ten  per  cent;  aristol,  five  to  eight  per  cent;  gum  benzoin  or 
myrrh,  twenty  per  cent;  berberine  muriate,  ten  per  cent;  cocaine,  two 


552  DISEASES  OF  THE  NASAL   CAVITIES. 

or  three  per  cent.  The  sprays  contain  of  menthol  one-tenth  to  one- 
fifth  of  one  per  cent,  carbolic  acid  one-fifth  of  one  per  cent,  oil  of  cloves 
one-half  to  one  per  cent  (Form.  104  to  10G).  Ichthyol  used  as  a  spray  in 
five  per  cent  oily  solution  is  reported  to  have  given  good  results  in 
these  cases.  Where  the  secretion  is  profuse  and  of  a  muco-purulent 
character,  from  one-eighth  to  one-half  grain  to  the  ounce  of  mercury 
bichloride  in  an  aqueous  solution  is  an  excellent  remedy.  Similar 
applications  should  be  made  by  the  physician  sufficiently  strong  to 
cause  discomfort  for  half  an  hour.  It  is  best  for  the  patient  at  first  to 
visit  the  physician  once  or  twice  a  week,  in  order  that  he  may  be  certain 
that  the  cleansing  process  is  properly  accomplished  and  that  the  ap- 
plications are  of  proper  strength,  but  after  a  short  time  twice  a  month 
is  usually  sufficient.  In  mild  cases  from  one  to  two  per  cent  of  cocaine 
added  to  the  powder  which  the  patient  uses  at  home  has  appeared  to 
have  a  most  beneficial  action  in  stimulating  the  flow  of  blood  to  the  parts. 

The  effects  of  cocaine  in  causing  contraction  of  the  blood  vessels  and  caver- 
nous tissue  is  well  known;  it  is  also  true  that  if  used  continually  for  a  considera- 
ble length  of  time,  it  frequently  increases  the  congestion  and  swelling,  which 
probably  accounts  for  the  benefit  sometimes  derived  from  its  use  in  these  cases. 

McDonald  (op.  cit.)  recommends  tincture  of  sanguinaria,  five  to 
thirty  drops  to  a  pint  of  warm  water;  also  tampons  saturated  with 
glycerin  or  boro-glyceride,  but  especially  Gottstein's  wool  tampons,  or 
what  he  terms  the  physical  method  of  stimulating  the  circulation  by 
partially  closing  the  nostrils  with  cotton  wool  and  causing  the  patient 
to  inhale  through  this  obstructing  mass  two  or  three  hours  daily.  He 
also  recommends  a  simple  nasal  respirator  for  a  similar  purpose.  D. 
Bryson  Delavan  (Xew  York  Medical  Journal,  1837)  and  other  laryngol- 
ogists  report  satisfactory  results  from  stimulating  the  mucous  mem- 
brane with  the  electric  current,  the  positive  pole  applied  to  the  nape  of 
the  neck,  the  negative  to  the  mucous  membrane  by  means  of  a  piece 
of  copper  wire  enclosed  in  a  pledget  of  moistened  cotton,  with  a 
current  of  from  four  to  seven  milliamperes.  In  addition  to  the  local 
remedies,  great  benefit  is  often  derived  from  constitutional  treatment. 
Quinine,  iron,  strychnine,  arsenious  acid  in  some  form,  and  iodine  are 
most  beneficial.  The  latter,  in  moderate  doses  just  sufficient  to  excite 
nasal  secretion,  is  frequently  found  most  advantageous.  Good  diet 
and  proper  clothing  should  always  be  supplied,  and  a  change  of  climate 
will  sometimes  be  found  beneficial. 


CHAPTER   XXXII. 

DISEASES   OF    THE    NASAL  CAVITIES.— Continued. 

HAY   FEVER. 

Synonyms. — Hay  asthma,  rose  cold,  June  cold,  autumnal  catarrh, 
rhinitis  hyperaesthetica,  catarrhus  sestivus. 

Hay  fever  is  one  of  the  neuroses  occurring  periodically  and  charac- 
terized by  irritation  and  inflammation  of  the  mucous  membrane  of  the 
eyes,  nose  and  air  passages,  attended  by  profuse  secretion  and  asthmatic 
attacks.  Isolated  cases  may  occur  at  any  time  of  the  year,  but  in  this 
country  the  affection  usually  prevails  from  about  the  middle  of  August 
until  the  latter  part  of  September,  or  until  the  early  frosts;  though  a 
considerable  number  of  cases  are  observed  in  May,  June,  and  July,  and 
occasional  instances  even  in  mid-winter.  In  England  it  is  most  preva- 
lent in  June  and  July.  It  is  rather  more  common  in  men  than  in  women. 
It  occurs  at  all  ages,  but  is  most  frequent  before  the  prime  of  life;  I 
have  seen  it  in  children  five  years  of  age,  and  have  known  it  to  afflict 
those  as  old  as  eighty  or  ninety.  Seldom  found  among  the  working 
classes,  it  attacks  preferably  those  of  education  and  cultivation,  and  res- 
idents of  towns  and  cities  rather  than  dwellers  in  the  open  country. 

Anatomical  and  Pathological  Characteristics. — The  inflam- 
mation generally  affects  the  nasal  mucous  membrane  and  conjunctivas, 
but  often  extends  to  the  frontal  sinuses,  and  may  be  severe  in  the  fauces 
or  entire  respiratory  tract.  The  membrane  is  usually  highly  congested 
and  swollen,  but  in  some  cases,  although  swollen,  it  is  much  paler  than 
normal.  Though  its  pathology  is  not  fully  understood,  the  affection 
apparently  results  from  a  peculiar  irritability  of  the  nervous  system, 
sometimes  being  manifested  by  constitutional  symptoms  and  again  by 
localized  abnormal  sensibility  either  in  the  whole  or  a  part  of  the  respi- 
ratory mucous  membrane. 

Etiology. — Heredity  and  nervous  temperament  predispose  to  this 
affection,  but  a  great  variety  of  substances  may  excite  the  attack  where 
the  predisposition  exists.  William  H.  Daly,  first  pointed  out  the  re- 
lation between  hay  fever  and  certain  morbid  conditions  in  the  nasal 
passages  (Transactions  of  the  American  Laryngological  Association, 
1881).  Subsequently  his  observations  were  repeated,  and  his  conclu- 
sions confirmed,  by  Roe,  Hack,  J.  N.  Mackenzie,  Sajous,  and  others; 
and  although  the  disease  is  not  so  uniformly  dependent  upon  the  condi- 


554  DISEASES  OF  THE  NASAL   CAVITIES. 

tion  of  the  nasal  mucous  membrane  as  some  of  these  authors  supposed, 
yet  in  most  cases  such  a  relation  is  undoubted.  Commonly  the  attack 
appears  to  be  brought  on  by  inhalation  of  the  pollen  of  ambrosia  arte- 
misia?  folia,  known  also  as  Roman  wormwood,  rag-weed,  or  hog-weed,  or 
that  of  solidago  odora,  known  commonly  as  golden-rod,  but  it  is  frequently 
excited  by  dust  and  smoke,  especially  in  railway  travel,  and  by  the 
emanations  of  roses  and  other  fragrant  plants,  or  the  pollen  of  certain 
grasses,  as  wheat,  barley,  oats,  rye,  or  even  indian  corn.  It  may  also 
be  excited  by  the  dust  of  ipecac,  salicylic  acid,  benzoic  acid,  and  lyco- 
podium,  and  sometimes  it  is  brought  on  by  exposure  to  heat  or  light, 
or  by  over-fatigue.  So  strong  is  the  neurotic  influence  in  this  disease 
that  imagined  exposure  to  influences  which  had  formerly  excited  an 
attack  have  been  sufficient  to  induce  the  return  of  the  paroxysm;  for 
example,  an  artificial  flower  or  even  the  painting  of  a  full-blown  rose 
has  brought  on  an  attack  of  the  disease. 

Symptomatology. — The  attacks  often  come  on  the  same  date  of  suc- 
ceeding years,  regardless  of  the  temperature,  the  conditions,  or  surround- 
ings; but  in  some  is  a  variation  of  a  few  days,  apparently  dependent 
upon  atmospheric  conditions  or  environment.  There  are  two  well- 
marked  types,  the  catarrhal  and  the  asthmatic.  In  the  former  the  dis- 
ease usually  comes  on  suddenly,  with  irritation  of  the  mucous  membrane 
of  the  fauces,  conjunctivae,  and  nares,  attended  by  frequent  sneezing; 
in  the  latter,  asthmatic  features  are  usually  developed  after  the  nasal 
symptoms  have  existed  two  or  three  weeks,  but  they  may  come  on  inde- 
pendently. The  asthma  in  this  affection  commonly  differs  from  ordinary 
spasmodic  asthma  in  that  the  paroxysms  are  likely  to  occur  during  the 
day-time. 

In  most  instances  the  patient  is  made  aware  of  the  onset  of  the 
disease  by  a  tickling  or  stinging  sensation  in  the  Schneiderian  mucous 
membrane,  accompanied  by  violent  sneezing  and  itching  of  the  con- 
junctiva?, with  profuse  lachrymation;  or  by  burning  or  stinging  sensa- 
tions in  the  throat,  or  in  some  instances  by  severe  neuralgic  pains  in 
the  eyeballs  or  back  part  of  the  head.  Swelling  of  the  conjunctiva?, 
eyelids,  lips,  or  tip  of  the  nose  is  frequently  present.  Constitutional 
symptoms  are  often  marked  by  elevation  of  temperature,  aching  of  the 
muscles,  general  malaise,  and  sometimes  great  weakness.  One  of  the 
most  uniform  concomitants  is  swelling  of  the  Schneiderian  mucous 
membrane,  which  causes  obstruction  of  the  nares,  and  thus  interferes 
with  respiration,  in  many  cases  leading  to  the  asthmatic  attacks.  Pro- 
fuse watery  discharge  from  the  nose,  subsequently  becoming  muco- 
purulent, and  which  is  often  very  irritating,  is  nearly  always  present. 
The  mucous  membranes  affected  are  usually  of  a  bright  red  color, 
though  occasionally  anaemic. 

Diagnosis. — Hay  fever  may  be  confounded  with  simple  acute  rhini- 
tis or  spasmodic  asthma.     The  essential  points  of  difference  are  the  his- 


HAY  FEVER.  555 

tory,  the  abrupt  commencement,  the  excessive  irritation;  and  the  oc- 
currence of  asthmatic  paroxysms  during  the  day  instead  of  at  night. 
This  history,  together  with  the  detection  of  very  sensitive  areas  of  the 
nasal  mucous  membrane  by  lightly  touching  it  with  the  probe,  are  suffi- 
cient to  establish  the  diagnosis,  except  during  first  attacks  or  in  young 
children,  where  it  is  sometimes  necessary  to  watch  the  patient  for  some 
time.     Urticaria  is  frequently  observed  in  connection  with  hay  fever. 

Prognosis. — The  attacks  usually  continue,  with  daily  varying  se- 
verity, from  four  to  six  or  eight  weeks,  according  to  the  patient's 
surroundings  and  the  atmospheric  conditions,  and  not  infrequently 
the  patient  remains  greatly  debilitated  for  several  months.  The 
asthmatic  attacks  may  continue  several  hours  or  two  or  three  days,  and 
then  disappear  as  suddenly  as  they  came.  Some  lose  susceptibility  to 
the  disease  with  advancing  years.     The  affection  is  not  dangerous  to  life. 

Treatment. — In  most  cases  the  attacks  maybe  prevented  by  change 
of  climate — sometimes  a  change  from  city  to  country  or  vice  versa  is 
sufficient — but  most  patients  find  the  greatest  relief  in  cool  localities  by 
the  northern  lakes,  in  places  near  the  seashore,  or  at  high  altitudes; 
or  from  a  lake  or  ocean  trip,  which  removes  them  from  the  pollen- 
laden  air.  In  this  country,  the  most  favored  spots  are  in  the  White 
Mountains  of  New  Hampshire,  and  in  the  region  about  Mackinac, 
in  the  northern  part  of  Michigan.  Many  obtain  complete  immunity 
from  the  disease  in  the  high  altitudes  of  our  western  states  and  terri- 
tories. No  locality  will  be  found  equally  beneficial  for  all  individuals, 
and  some  will  suffer  severely  where  others  have  complete  relief. 

As  the  disease  commonly  occurs  in  neurasthenic  persons,  nerve 
tonics  and  sedatives  are  especially  indicated.  It  is  well  to  begin  the 
administration  of  these  remedies  a  month  before  the  attack  usually 
comes  on,  and  to  continue  them  until  convalescence  is  established.  To 
this  end  the  various  preparations  of  quinine,  strychnine,  or  arsenious 
acid,  and  asafcetida  or  some  of  the  preparations  of  valerian  are  most 
serviceable.  I  have  found  peculiarly  beneficial  a  pill  containing  medium 
doses  of  brucia  phosphate,  alcoholic  extract  of  hyoscyamus,  quinine 
valerianate,  and  camphor  monobromate,  with  or  without  small  doses  of 
sodium  salicylate,  phenacetin,  acetanilid,  or  asafcetida.  These  may  be 
given  before  and  during  the  attack,  with  the  effect  of  greatly  mitigating 
the  patient's  sufferings.  During  the  attack,  opiates  and  belladonna  in 
small  doses  are  often  of  the  greatest  benefit;  for  example,  five  to  eight 
drops  of  the  tincture  of  belladonna  or  the  deodorized  tincture  of  opium, 
or  both  combined;  or  instead  of  these  from  a  twelfth  to  an  eighth  of  a 
grain  of  morphine,  or  from  one  two-hundredth  to  one  one-hundred-and- 
twentieth  of  a  grain  of  atropine,  or  both  together.  Atropine  in  small 
doses  or  hyoscyamus  is  especially  beneficial  in  checking  the  profuse 
secretion  and  tendency  to  sneeze;  the  after  effects  of  the  latter  are  less 
likely  to  be  unpleasant.     Local   stimulating  inhalations,  of  ammonia, 


DISEASES   OF  THE  NASAL    CAVITIES. 

iodine,  or  chloroform  are  sometimes  useful,  though  they  must  he  em- 
ployed  guardedly  lest  tbey  increase  the  irritation. 

Fur  relief  from  the  itching  of  the  conjunctiva?,  weak  solutions  of  lead 
acetate  are  especially  recommended  by  Mackenzie.  I  have  found  most 
beneficial  a  solution  of  sodium  biborate  gr.  v.  to  x.  ad  3  i.  of  camphor 
water.  With  this,  the  eyes  may  be  bathed  as  frequently  as  desired. 
The  lips  and  nostrils  may  be  protected  from  the  irritating  effect  of  the 
secretion  by  applying  the  ointment  of  zinc  oxide,  or  better  the  iodol 
and  lanolin  ointment  (Form.  9),  to  each  ounce  of  which  has  been  added 
ten  or  twenty  grains  of  zinc  oxide.  The  irritation  of  the  nasal  mucous 
membrane  may  sometimes  be  largely  prevented  by  wearing  plugs  of 
wool  in  the  nostrils  to  exclude  dust  and  other  irritating  substances. 
Bathing  the  eyes  and  nose  with  either  of  the  solutions  recommended, 
or  with  very  hot  or  very  cold  water,  will  sometimes  give  great  relief. 

As  a  local  application  to  the  Schneiderian  mucous  membrane,  a  spray 
of  a  saturated  solution  of  boric  acid  will  sometimes  be  found  very  grate- 
ful. In  some  instances  it  is  well  to  make  this  solution  in  camphor 
water;  in  others  it  will  be  necessary  to  add  to  it  small  quantities  of 
atropine,  morphine,  or  cocaine.  The  latter  remedy  gives  more  immediate 
relief  than  any  other  we  possess;  but  unfortunately  its  continued  use  is 
frequently  followed  by  most  serious  consequences.  With  some  patients, 
oily  sprays  will  be  found  more  beneficial.  For  this  purpose  a  most 
excellent  combination  is  that  of  thymol  gr.  ^,  oil  of  cloves  iTliij.,  and 
liquid  albolene  3!.,  to  which  in  some  cases  a  small  amount,  not  more 
than  one-half  of  one  per  cent,  of  the  alkaloid  cocaine  may  be  added. 
The  strength  of  this  solution  may  be  slightly  incieased  in  some  cases 
with  advantage,  but  care  should  be  taken  not  1 1  make  it  irritating. 
A  similar  spray  used  five  or  six  times  a  day  will  sometimes  prevent  the 
paroxysms  of  this  disease.  A  powder  containing  three  or  four  per 
cent  of  cocaine  hydrochlorate  (Form.  166)  will  be  found  more  convenient 
for  general  application.  In  whatever  way  cocaine  is  employed,  the 
patient  should  not  use  more  than  one-third  of  a  grain  daily,  and  this 
should  not  be  long  continued.  Because  of  the  temporary  relief  af- 
forded, patients  are  very  apt  to  use  this  remedy  to  excess,  therefore 
physicians  should  never  give  written  prescriptions  containing  it,  and 
should  insist  upon  knowing  exactly  how  much  the  patient  is  using.  I 
have  known  several  lives  wrecked  by  neglect  of  this  precaution.  During 
an  acute  attack  of  hay  fever,  nasal  douches  of  weak  solutions  of  quinine, 
salicylic  acid,  sulphurous  acid  or  other  antiseptics  have  been  recom- 
mended on  the  theory  that  the  irritation  is  due  to  the  local  action  of 
microbes.  These  applications  seem  to  have  been  beneficial  in  the  hands 
of  some  physicians,  but  in  my  experience  they  have  been  disappointing. 

When  the  attacks  are  due  to  sensitiveness  of  the  nasal  mucous 
membrane,  the  disease  may  be  cured  by  judicious  operative  measures. 
These  consist  in  removing  any  spur  from  the  septum  that  may  be  large 


HA  Y  FEVER.  557 

enough  to  impinge  upon  the  outer  wall,  the  removal  of  polypi,  linear 
cauterization  along  the  turbinated  body  to  prevent  extreme  swelling, 
and,  most  important,  superficial  cauterization  of  all  spots  found  to  be  ex- 
tremely sensitive.  The  superficial  cauterizations  should  simply  sear  the 
mucous  membrane,  leaving  it  in  much  the  same  condition  as  the  integu- 
ment after  a  blister;  it  must  not  be  burned  so  deeply  as  to  cause  any 
amount  of  cicatricial  tissue.  The  linear  cauterizations  are  the  same  as 
those  recommended  for  hypertrophic  rhinitis.  The  operations  on  the 
septum  and  for  polypoid  growths  are  described  elsewhere. 

The  nasal  cavity  should  first  be  thoroughly  examined  with  a  flat  probe, 
the  various  parts  being  gently  touched  and  the  sensitive  spots  marked 
upon  a  diagram  representing  the  two  surfaces  of  the  nares.  A  solution 
of  cocaine  (Form.  140)  is  then  applied  by  means  of  a  small  pledget  of 
absorbent  cotton  wound  on  the  end  of  a  flat  nasal  applicator  (Fig.  197). 
The  pledget  saturated  with  the  solution  is  carried  back  toNthe  posterior 
part  of  the  naris  and  as  it  is  brought  forward  is  rubbed  gently  over  every 
part  of  the  mucous  membrane  to  be  ana3sthetized.  This  occupies  about 
thirty  seconds.  A  minute  later  the  application  is  repeated  with  a  fresh 
pledget.     From  two  to  four  such  applications  are  generally  sufficient. 

The  cauterization  may  commonly  be  done  without  pain  as  soon  as  the 
patient  ceases  to  feel  the  probe  rubbed  lightly  over  the  surface,  even 
though  pressure  may  still  be  felt. 

The  part,  having  been  thoroughly  anaesthetized,  should  be  sprayed 
with  liquid  albolene,  and  then  rubbed  over  quickly  two  or  three  times 
with  a  flat,  guarded  electrode  (1,  Fig.  91)  until  a  spot  about  a  centimetre 
in  diameter  has  been  seared  and  appears  of  a  white  color.  It  should  not 
be  burned  deeply  enough  to  cause  an  appreciable  scar  after  healing  has 
taken  place.  The  cauterized  part  should  be  noted  upon  the  diagram, 
and  after  four  or  five  days  a  similar  cauterization  may  be  made  in  some 
other  part  of  the  nasal  cavities,  preferably  upon  the  opposite  side. 
These  operations  should  be  repeated  from  time  to  time  until  the  whole 
surface  has  been  treated  and  no  part  remains  peculiarly  sensitive  to  the 
probe. 

After  the  cauterization,  the  patient  may  be  given  a  four  per  cent 
powder  of  cocaine,  which  may  be  insufflated  into  the  nares  once  in  three 
to  five  hours  for  the  following  three  or  four  days.  Together  with  this 
it  is  well  to  give  an  oily  spray  similar  to  that  already  recommended. 
These  cauterizations  may  sometimes  be  repeated  every  two  or  three 
days;  but  it  is  generally  better  to  make  the  intervals  longer,  otherwise 
the  nares  are  apt  to  become  quite  sore,  and  the  patient  experiences 
much  discomfort.  When  the  longer  interval  is  allowed,  treatment  may 
usually  be  conducted  without  in  any  way  interfering  with  the  patient's 
vocation,  and  without  serious  discomfort.  From  fifteen  to  thirty  treat- 
ments are  generally  necessary  to  cover  all  of  the  diseased  surface.  The 
following  year   a  few  spots  may  be   found  still  sensitive,  which  were 


558  DISEASES  OF  THE  NASA  L   CAVITIES. 

overlooked  previously  or  not  burned  deeply  enough;  or  possibly  these 
may  result  from  new  development  of  the  disease. 

The  treatment  is  best  carried  out  during  the  warmer  portions  of 
the  year,  either  before  the  usual  time  of  the  attack  or  after  it  has 
subsided;  for  during  the  attack  it  is  liable  greatly  to  increase  the 
patient's  distress.  By  this  method  from  forty  to  fifty  per  cent  of  the 
oases  of  hay  lever  may  be  cured,  about  twenty-five  per  cent  more  may 
be  greatly  benefited,  and  the  remainder  will  usually  obtain  sufficient 
relief  from  the  nasal  symptoms  to  compensate  for  the  discomfort  expe- 
rienced during  the  treatment.  The  treatment  is  most  apt  to  be  bene- 
ficial where  asthma  has  not  yet  developed,  and  where  the  general  nervous 
symptoms  are  not  pronounced.  Cauterization  of  the  surfaces  with 
chromic  or  carbolic  acid  and  other  caustics  has  also  been  recommended. 
Asthmatic  attacks  occurring  in  connection  with  hay  fever  call  for  the 
same  treatment  as  simple  spasmodic  asthma.  It  is  always  best  for  the 
patient  to  seek  a  different  climate  during  the  season  if  possible;  and 
this  is  especially  important  in  those  who  suffer  from  debility  for  several 
weeks  or  months  after  the  attack,  and  in  children,  in  whom  we  may 
hope  to  cure  the  disease  by  interrupting  for  two  or  three  years  the 
vicious  habit  of  the  nervous  system,  which  otherwise  might  last  a  life- 
time. 

t 
FURUNCULOSIS   OF  THE   NOSE. 

Furunculosis  of  the  nose  is  a  comparatively  frequent  affection,  char- 
acterized by  the  development  of  small  pustules  or  larger  furuncles,  the 
cavities  of  which  vary  in  diameter  from  one  to  five  millimetres  or  more. 
These  suppurative  points  are  attended  by  redness  and  great  soreness  of 
the  end  of  the  nose,  and  a  larger  furuncle  by  constant  pain.  The 
inflammation  usually  originates  in  the  hair  follicle.  The  affection  lasts 
from  three  to  seven  days,  and.  upon  discharge  of  the  pus,  healing  quickly 
takes  place.  In  many  individuals  the  attack  frequently  recurs,  and  in 
some,  one  or  more  of  these  small  abscesses  are  nearly  always  present. 

Treatment. — As  in  all  other  abscesses,  the  indications  are  to  evac- 
uate the  pus;  but  it  is  most  important  to  adopt  some  measure  which  will 
prevent  a  recurrence  of  the  attack.  For  this  purpose  remedies  calcu- 
lated to  prevent  the  occurrence  of  suppuration  in  any  part  of  the  body 
are  indicated,  such  as  calcium  sulphide,  potassium  chlorate,  saline  diu- 
retics and  laxatives;  brewers'  yeast  has  also  been  used  for  this  purpose, 
with  apparent  success.  Of  the  above,  potassium  chlorate  has  seemed  to 
me  most  valuable.  Local  applications  of  tincture  of  iodine  or  solutions 
of  silver  nitrate  and  of  various  oils  and  ointments  have  been  employed, 
with  almost  uniformly  unsatisfactory  results:  for  although  the  remedies 
appear  beneficial  at  the  time,  the  affection  persistently  recurs.  It  is 
true  that  in  many  cases  any  of  these  remedies  may  be  used  with  appar- 


EPIiSTAArIlS.  559 

ent  benefit;  but  it  is  doubtful  in  such  instances  whether  the  patient 
would  not  have  recovered  almost  as  speedily  without  them.  In  obstinate 
examples  the  fact  remains  that  local  applications,  as  a  rule,  do  but  little 
good.  In  two  or  three  cases,  under  a  suggestion  for  which  I  am  in- 
debted to  J.  E.  Best,  of  Arlington  Heights,  111.,  I  have  seen  speedy  im- 
provement and  permanent  cure  result  from  the  use,  four  or  five  times 
daily  for  two  or  three  weeks,  of  a  two  per  cent  aqueous  solution  of  car- 
bolic acid,  which  should  be  thoroughly  applied  Avith  a  small  swab  of 
absorbent  cotton  wound  upon  a  toothpick  or  other  applicator. 

EPISTAXIS. 

Synonyms. — Nose-bleeding,  hemorrhagia  narium. 

Epistaxis  consists  of  hemorrhage  from  the  nose,  originating  either  in 
the  nasal  cavities  or  the  adjacent  sinuses.  It  is  most  frequent  about 
the  age  of  puberty,  is  more  common  in  early  childhood  and  advanced 
age  than  in  the  prime  of  life,  and  occurs  more  often  in  men  than  in 
women. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membrane  may  be  congested  and  swollen,  or  may  appear  normal;  but  in 
most  cases  erosion,  actual  ulceration,  or  a  small  bleeding  point  may  be 
found  upon  the  cartilaginous  septum.  Sometimes  the  septum  is  per- 
forated, and  the  bleeding  comes  from  the  edge  of  the  opening.  In  other 
cases  the  mucous  membrane  is  thin  and  the  blood  vessels  are  near  the 
surface,  so  as  to  easily  rupture  upon  engorgement  from  any  cause. 
Occasionally  the  bleeding  comes  from  the  mucous  membrane  over 
the  turbinated  bodies,  from  the  adjacent  sinuses  or  posterior  nares,  or 
from  the  easily  bleeding  surface  of  a  fibrous  or  malignant  tumor. 

Etiology. — Among  the  local  causes  are  injury  from  picking  the 
nose,  the  introduction  of  instruments,  violent  sneezing,  coughing,  strain- 
ing, the  inhalation  of  irritants,  or  the  presence  of  polypi  or  other  foreign 
bodies  in  the  nasal  passages.  The  constitutional  causes  are  alterations 
of  the  blood,  such  as  occur  in  anaemia,  plethora,  eruptive  and  relapsing 
fevers,  diphtheria,  scurvy,  purpura,  and  haemophilia;  or  changes  in  the 
walls  of  the  blood  vessels  accompanying  phosphorus  poisoning,  acute 
yellow  atrophy  of  the  liver,  Bright's  disease,  gout,  rheumatism,  and  oc- 
casionally syphilis  or  chronic  alcoholism.  The  affection  is  also  due  in 
some  instances  to  obstructed  circulation  through  the  jugular  vein,  en- 
gorgement of  the  right  ventricle,  obstructed  pulmonary  circulation  as 
in  severe  bronchitis  or  emphysema,  or  to  engorgement  of  the  liver  or 
kidneys;  and  it  may  result  from  the  effects  of  strong  emotional  excite- 
ment upon  the  vasomotor  nerves.  It  is  sometimes  vicarious,  taking  the 
place  of  menstruation  or  of  the  habitual  bleeding  from  hemorrhoids. 

Symptomatology. — In  the  plethoric,  and  in  patients  suffering  from 
fever,  the  bleeding  is  often  preceded  by  flushing  of  the  face,  a  sense  of 


560  DISEASES   OF  THE  NASAL   CAVITIES. 

fulness  in  the  head,  with  buzzing  in  the  ears,  and  giddiness,  and  some- 
times itching  in  the  nose.  It  usually  begins  without  apparent  cause, 
frequently  even  while  the  patient  is  asleep,  and  flows  from  one  side 
in  drops,  which  follow  each  other  in  rapid  succession;  in  severe  cases 
it  may  run  in  a  small  stream.  Usually  not  more  than  a  drachm  of  blood 
is  lost  at  one  time,  although  it  may  seem  very  much  more,  to  the  patient 
and  his  friends;  but  in  others,  bleeding  is  rapid  and  persistent,  and 
sometimes  sufficient  to  prove  fatal.  A  large  amount  of  blood  may  be 
lost  within  a  few  hours,  and  the  bleeding  may  continue  for  several  days. 
Martineau  mentions  a  case  in  which  twelve  pints  of  blood  were  lost  in 
sixty  hours  (&  Union  Medicale,  1868,  troisieme  serie,  Tome  VI).  When 
the  bleeding  is  excessive,  syncope  is  liable  to  occur,  and  may  prove 
fatal.  Where  epistaxis  occurs  frequently,  or  continues  for  several  days, 
serious  anaemia  may  result.  Usually  bright  red  blood  flows  from  one 
nostril  only,  but  it  may  pass  back  to  the  posterior  nares  and  escape 
around  the  septum  from  the  other  nostril,  or  run  down  the  throat. 

Diagnosis. — Simple  epistaxis  may  be  confounded  with  certain  neo- 
plasms, or  with  ulceration,  and  can  only  be  distinguished  therefrom  by 
careful  inspection  of  the  parts. 

Prognosis. — Most  cases  terminate  spontaneously  within  ten  or 
fifteen  minutes;  but  in  some  the  bleeding  continues  several  hours  or 
even  days.  The  cases  occurring  in  children  without  apparent  cause, 
and  those  resulting  from  various  injuries  to  the  nose,  are  seldom,  if  ever, 
dangerous.  When  occurring  in  old  people  without  provocation,  epi- 
staxis indicates  degenerative  changes  in  the  blood  vessels,  which  are 
ominous.  In  subjects  of  haemophilia,  bleeding  is  liable  to  prove  fatal. 
Nasal  hemorrhages  frequently  recurring  and'  lasting  several  days  at  a 
time,  unless  properly  treated,  cause  dangerous  anaemia,  and  many  there- 
fore terminate  fatally.  In  low  forms  of  fever,  and  in  diphtheria,  it  is  a 
grave  symptom.  As  has  been  shown  by  Hughlings  Jackson,  this  symptom 
occasionally  precedes  apoplexy  (London  Hospital  Clinical  Lectures  and 
Reports,  1866,  Vol.  Ill);  on  the  other  hand,  in  malarial  fever,  in 
plethora,  and  in  congestive  conditions  of  the  brain,  the  bleeding  is  some- 
times beneficial.  Instances  are  on  record  in  which  mania,  epilepsy,  and 
asthma  seem  to  have  been  induced  by  checking  the  flow. 

Treatment. — In  the  majority  of  cases  the  bleeding  does  no  harm 
and  need  receive  no  treatment.  When  of  a  vicarious  nature,  and  where 
there  is  evidence  of  plethora  or  of  obstructed  venous  circulation,  it 
should  not  be  checked  unless  long  continued.  Owing  to  the  fact  that 
most  cases  stop  spontaneously  within  ten  or  fifteen  minutes,  a  great 
variety  of  methods  for  checking  bleeding  from  the  nose  are  implicitly 
relied  on  by  the  laity.  To  aid  in  checking  hemorrhage,  the  head  should 
be  kept  erect,  applications  of  cold  may  be  made  to  the  neck  or  directly 
to  the  nose,  or  the  application  of  hot  water  at  a  temperature  of  120°  to 
I25c  F.     As  in  most  instances  the  blood  flows  from  a  small  point  on  the 


EPI8TATI8.  '  561 

cartilaginous  septum,  it  is  easy  to  check  it  by  continuous  compression 
of  the  alse  nasi  for  ten  or  fifteen  minutes  or  by  direct  pressure  of  the 
finger  upon  the  septum.  Compression  of  the  facial  artery  is  also  recom- 
mended. 

In  continued  bleeding  which  occurs  from  points  far  back  in  the 
Dares,  other  methods  must  be  employed.  The  insufflation  of  pow- 
dered alum,  tannin,  or  matico  leaves  will  often  be  found  efficient.  The 
alum  is  liable  to  cause  excessive  pain,  and  tannin  also  is  frequently  pain- 
ful; powdered  matico,  however,  has  been  found  much  less  painful,  and  ap- 
parently is  quite  as  effective.  The  application  of  a  spray  of  tannin  gr.  x. 
ad  3  i.  answers  well  in  some  cases,  or  a  solution  of  iron  perchloride  TT[  xx. 
ad  |  i.  may  be  used  in  the  same  way;  of  the  two,  the  tannin  is  prefera- 
ble. Injections  of  ice  water,  or  better,  small  bits  of  ice  frequently 
introduced,  are  often  satisfactory.  Internal  remedies  may  be  given  at 
the  same  time  with  more  or  less  benefit.  For  this  purpose  the  fluid 
extract  of  ergot  in  doses  of  half  a  drachm  every  one  to  two  hours,  or 
ergotine  in  proportionate  quantity,  is  recommended;  also,  tincture  of 
opium  in  doses  of  from  five  to  eight  minims  or  medium  doses  of  lead 
acetate,  alone  or  combined  with  opium. 

In  the  epistaxis  of  purpura,  MacXamara  commends  a  wineglassful 
of  spirits  of  turpentine  in  a  tumbler  of  brandy  or  whiskey  punch  taken 
as  rapidly  as  possible  (Mackenzie:  "Diseases  of  the  Xose  and  Throat," 
1884).  Harkin,  of  Belfast,  Ireland,  claims  to  have  obtained  excellent 
results  (Transactions  of  the  Mirth  International  Medical  Congress, 
Vol.  IV),  in  preventing  the  recurrence  of  epistaxis  by  counter-irritation 
over  the  liver.  In  persistent  bleeding,  when  simple  remedies  fail,  plug- 
ging must  be  resorted  to. 

Simple  plugging  of  the  nostril  with  cotton  or  lint,  and  holding 
the  head  forward  until  coagulation  has  taken  place,  will  be  sufficient 
in  many  cases.  When  it  fails,  plugging  of  the  posterior  nares  must 
be  the  resort,  or  better  still,  filling  the  whole  nasal  cavity  with  a 
styptic  and  antiseptic  tampon  of  gauze  or  lint.  Sometimes  the  nares 
may  be  easily  and  effectually  plugged  by  an  air  sack,  operated  on  the 
plan  of  Barnes'  uterine  dilator,  but  this  method  is  not  usually  very 
successful.  Compressed  sponge  or  simply  strips  of  sponge  may  be 
packed  into  the  nares  with  the  forceps  or  applicator  and  will  usually 
quickly  check  bleeding,  but  these  are  removed  with  difficulty,  and 
occasionally  some  jfiece  is  left  behind,  causing  an  infinite  amount 
of  trouble,  which  might  be  avoided  by  carefully  tying  each  bit  of 
sponge  with  a  strong  thread,  and  numbering  the  threads  by  knots  to 
indicate  which  should  be  removed  first.  One  of  the  most  convenient 
tampons  for  the  nose  is  made  by  tying  a  strong  thread  to  the  middle 
of  a  bundle  of  fifteen  or  twenty  ravellings  from  surgeon's  lint,  about 
four  inches  in  length;  one  or  more  of  these  bundles  being  used.  After 
the  naris  is  filled,  all  of  the  threads  may  be  wound  about  a  bit  of  lint 
x6 


562  DISEASES   UF   THE  NASAL   CAVITIES. 

and  tucked  into  the  nostril.  This  tampon  has  the  merit  of  causing 
little  pain  and  of  being  easily  extracted,  providing  the  threads  have 
been  numbered  as  already  mentioned.  In  using  any  of  these,  it  is  well 
first  to  blow  into  the  naris  four  or  five  grains  of  iodoform  or  of  a  mix- 
ture of  equal  parts  of  iodoform  and  boric  acid. 

A  most  efficacious  method  of  checking  excessive  bleeding  from  the 
nose,  which  I  adopted  some  years  ago,  and  one  easy  of  application,  con- 
sists of  saturating  a  strip  of  antiseptic  gauze  about  an  inch  in  width  by 
four  feet  in  length  with  a  thick  syrupy  mixture  of  tannin  in  water,  to 
which  has  been  added  a  little  glycerin  and  a  few  drops  of  carbolic  acid. 
This  is  stuffed  into  the  nose,  fold  after  fold,  until  the  naris  is  filled. 
Sometimes  to  the  end  first  introduced,  I  attach  three  or  four  strung 
threads  about  two  inches  apart.  This  end  is  then  passed  through  the 
naris  into  the  naso-pharynx,  the  free  ends  of  the  thread  being  left  hang- 
ing from  the  nostril.  The  strip  is  then  rapidly  pushed  in  until  the 
posterior  part  of  the  cavity  is  full,  after  which  the  threads  are  drawn 
upon  so  as  to  pack  the  gauze  firmly  into  the  posterior  naris.  The 
whole  cavity  is  then  filled  with  the  strip  of  gauze,  any  remaining  por- 
tion being  cut  off.  This  is  to  me  the  most  satisfactory  means  of  plug- 
ging the  naris,  and  has  proved  efficient  in  the  most  severe  cases  where 
jiosterior  plugging  would  be  indicated.  The  gauze  may  be  rapidly  and 
easily  introduced,  and  readily  removed,  and  the  method  obviates  the 
danger  of  pressure  upon  the  openings  of  the  Eustachian  tubes  and 
consequent  inflammation  of  the  middle  ear.  The  only  disadvantages 
I  have  observed  are  that  its  removal  is  sometimes  painful,  especially 
after  operative  procedures  in  the  nose,  and  the  tannin  causes  some  in- 
dividuals considerable  smarting.  Walton  Browne,  of  Belfast,  Ireland, 
recommends  a  similar  procedure,  the  gauze  being  impregnated  with 
powdered  alum  instead  of  tannin,  and  he  says  it  is  not  painful  (Trans- 
actions of  the  Ninth  International  Medical  Congress,  Vol.  IV),  though 
from  my  observation  alum  appears  to  cause  much  more  smarting  than 
tannin. 

Plugging  the  posterior  nares  has  long  been  practised  for  checking 
obstinate  epistaxis.  It  is  commonly  performed  with  the  aid  of  Bellocq's 
canula,  by  drawing  through  the  nose  from  the  throat  a  strong  string  to 
which  is  attached  a  plug  of  cotton  or  lint  of  a  sufficient  size  to  fill  the 
posterior  naris.  By  traction  on  the  string,  this  plug  is  firmly  packed 
into  the  choana.  A  plug  is  then  introduced  into  the  nostril,  and  the 
string  tied  about  it.  Lint  is  much  preferable  to  cotton  for  either  of 
these  plugs,  as  the  latter  tends  constantly  to  become  smaller  when  it  be- 
comes saturated  with  the  secretions.  A  loorj  at  least  two  inches  in 
length  should  be  left  hanging  from  the  plug  that  is  drawn  into  the 
posterior  naris,  or  a  string  should  be  attached  and  left  protruding  from 
the  mouth  to  aid  in  removing  the  tampon.  Both  sides  may  be  treated 
in   the  same   way,   but  the  impaction  of   a  large  mass  into  the  naso- 


EPISTAZ1S.  503 

pharynx  is  to  be  deprecated.  It  is  unsafe  to  leave  the  post-nasal  plug 
in  position  for  more  than  twenty-four  hours  without  renewal,  as  inflam- 
mation of  the  middle  ear  or  suppuration  of  the  mastoid  cells  is  liable 
to  follow  such  practice,  and  occasionally  death  from  gangrene,  tetanus, 
erysipelas,  or  septicemia  has  resulted.  To  remove  the  tampon,  the 
pledget  should  be  taken  from  the  nostril,  and,  when  only  one  side  has 
been  stopped,  warm  water  to  which  has  been  added  a  teaspoonful  of 
sodium  bicarbonate  to  each  pint  should  be  gently  injected  through  the 
opposite  side  to  loosen  the  tampon.  The  affected  side  may  be  carefully 
washed  in  the  same  way,  but  force  should  not  be  used.  The  string 
hanging  in  the  pharynx  or  protruding  from  the  mouth  should  then  be 
pulled  upon,  and  if  necessary,  the  tampon  gently  pressed  back  by  a 
probe  until  it  is  released  and  drawn  out  through  the  mouth.  An  ordi- 
nary soft  catheter  is  often  more  convenient  for  introducing  the  string 
than  the  Bellocq's  canula;  it  is  passed  through  the  nostril  into  the 
throat  and  drawn  out  at  the  mouth  by  forceps ;  a  suitable  thread  is  then 
attached  and  drawn  back  through  the  naris.  A  well  waxed  thread  may 
usually  be  easily  passed  through  the  naris  without  the  aid  of  catheter 
or  sound. 

To  prevent  recurrence  of  the  attack,  the  cause  must  be  sought  and 
removed.  In  the  majority  of  cases  this  will  be  found  in  a  bleeding 
point  upon  the  cartilaginous  septum,  but  occasionally  upon  other  por- 
tions of  the  mucous  membrane.  Sometimes  cauterization  of  this  with 
solid  silver  nitrate  will  be  sufficient  to  cure ;  but  usually  it  is  best  to 
touch  it  with  the  galvauo-cautery,  the  point  of  which  should  be  heated 
to  a  cherry-red  and  quickly  touched  to  the  spot  several  times,  until  the 
surface  is  thoroughly  seared.  In  most  cases  a  single  treatment  of  this 
kind,  provided  the  exact  spot  has  been  found,  is  sufficient  to  effect  a 
cure,  but  in  others  subsequent  cauterization  will  be  necessary. 


CHAPTER  XXXIII. 

DISEASES   OF   THE   NASAL   CAVITIES.— Continued. 

.NASAL  MUCOUS   POLYPI. 

Syn on y m. — Nasal  myxomata. 

Nasal  myxomata  are  tumors  which  grow  from  some  part  of  the  mu- 
cous surface,  producing  obstruction  of  the  passages  and  usually  excessive 
mucous  discharge.  They  are  very  common,  occurring  more  often  in 
men  than  in  women,  but  are  seldom  seen  in  children  under  twelve  years 
of  age. 

Anatomical  and  Pathological  Characteristics. — Mucous  polypi 
are  grayish  or  pinkish  in  color  and  semi-transparent;  they  are  round, 
oval,  or  pyriform,  and  vary  in  size  from  five  to  fifty  millimetres  in 
diameter.  They  are  somewhat  yielding  and  elastic  to  the  touch,  their 
surface  being  smooth  and  often  marked  by  minute  blood  vessels.  They 
are  commonly  pedunculated,  but  sometimes  sessile;  they  are  generally 
multiple,  and  in  about  thirty  per  cent  of  all  cases  occur  on  both  sides. 
Most  of  them  spring  from  the  middle  meatus  or  the  external  surface 
of  the  middle  turbinated  body,  a  considerable  number  from  the  superior 
turbinated  body  and  superior  meatus,  and  not  a  few  from  the  ethmoid 
cells.  They  occasionally  start  in  the  antrum  or  frontal  sinus,  and  very 
rarely,  spring  from  the  septum.  These  tumors  are  usually  covered  with 
ciliated  epithelium,  beneath  which  are  found  a  few  dilated  capillaries. 
Nerves  have  not  been  traced  into  these  growths,  but  that  they  contain 
nervous  filaments  is  demonstrated  beyond  perad venture  by  the  pain 
caused  by  cutting  them  off.  The  bulk  of  the  polypoid  mass  is  made 
up  of  embryonic  connective  tissue  and  a  gelatinous  substance  rich  in 
mucin,  the  density  of  the  growth  depending  on  the  degree  in  which  the 
connective  stroma  or  mucous  substance  predominates.  Sometimes  their 
structure  is  fibro-cellular. 

Etiology. — Though  their  ultimate  cause  is  not  known,  polypi  are 
generally  attributed  to  chronic  congestion  or  to  the  irritation  resulting 
from  denuded  bone.  Woakes  holds  that  mucous  polypi  are  always  as- 
sociated with  necrosis  of  the  ethmoid  bone  (Nasal  Polypi  with  Neu- 
ralgia, Hay  Fever,  etc.,  H.  R.  Lewis,  London).  While  this  may  be  an 
antecedent  in  many  cases  of  polypi,  either  condition  not  infrequently 
occurs  independent  of  the  other. 

Symptomatology. — At  first  the  patient  suffers  from  increased  nasal 


NASAL  MUCOUS  POLYPI.  565 

secretion  and  more  or  less  occlusion  of  the  nasal  passages,  which  is  often 
aggravated  by  damp  weather,  and  is  increased  by  colds,  to  which  he  is 
very  susceptible.  The  occlusion  is  usually  more  marked  in  one  naris, 
but  the  sense  of  obstruction  frequently  changes  quickly  from  one  side 
to  the  other.  Nightmare,  headache,  giddiness,  epilepsy,  congestion  of 
the  fauces,  hay  fever,  asthma,  and  other  reflex  disturbances  sometimes 
result  from  the  presence  of  these  growths;  but  Mackenzie  justly  re- 
marks (Diseases  of  the  Throat  and  Nose) : 

Whilst  fully  admitting  that  many  reflex  phenomena  may  arise  from  dis- 
eases within  the  nose,  I  must  caution  the  younger  specialist  that  the  various 
complaints  referred  to  as  resulting  from  nasal  disease  are  much  more  frequently 
due  to  other  conditions,  and  that  every  other  possible  cause  must  be  eliminated 
before  the  nose  is  incriminated. 

Bosworth  shows  that  mucous  polypi  are  found  in  thirty-two  per  cent 
of  all  cases  of  asthma  (Diseases  of  the  Throat  and  Nose,  1889,  Vol.  I). 

Patients  often  experience  a  sensation  as  of  a  movable  foreign  body 
in  the  nose;  headaches  are  comparatively  common,  and  the  senses  of 
smell  and  taste  are  often  obtunded,  although  in  many  cases  they  may  be 
restored  by  the  removal  of  the  growth.  The  voice  is  modified  in  a 
characteristic  manner  by  the  obstruction,  and  respiration  is  disturbed, 
so  that  the  patient  may  be  obliged  to  breathe  entirely  through  the  mouth. 
A  profuse  watery  and  sometimes  muco-purulent,  though  not  offensive, 
secretion  from  the  nose  is  common.  Epistaxis  is  not  infrequent. 
"When  the  tumor  protrudes  from  the  nostril,  it  is  usually  much  con- 
gested. By  anterior  or  posterior  rhinoscopy  the  smooth,  glistening, 
grayish  or  pinkish,  growths  may  be  seen ;  frequently  only  one  or  two 
large  ones  are  visible,  removal  of  which  discloses  many  more  of  smaller 
size.  A  flat  probe  may  be  easily  passed  upon  either  side  of  the  tumor, 
and  to  the  touch  it  is  found  soft  and  elastic. 

Diagnosis. — These  polypi  are  to  be  distinguished  from  deviation 
of  the  septum,  thickening  of  the  turbinated  bodies,  chronic  abscess  of 
the  septum,  foreign  bodies  in  the  nose,  and  from  fibrous,  sarcomatous, 
and  cancerous  growths. 

The  polypi  are  readily  distinguished  from  deviation  of  the  septum  by 
their  semi-translucency  and  the  fact  that  a  probe  may  be  passed  between 
them  and  the  septum. 

They  are  distinguished  from  thickening  of  the  turbinated  bodies  by 
their  color,  which  is  usually  much  lighter  ;  by  their  density,  which  is 
much  less;  by  passage  of  the  probe  between  them  and  the  external  wall 
of  the  naris,  and  by  their  movability. 

They  are  distinguished  from  chronic  abscess  of  the  septum  by  their 
color  and  density,  by  their  presence  usually  in  both  nares,  and  by  the 
passage  of  a  probe  between  them  and  the  septum. 

Mucous  polypi  resemble  foreign  bodies,  especially  in  causing  obstruc- 


DISEASES   OF   THE  NASAL   CAVITIES. 

tion  and  a  profuse  discharge,  but  the  discharge  in  the  case  of  foreign 
bodies  is  nearly  always  offensive — not  so  with  mucous  polypi.  The  his- 
tory of  the  case,  together  with  inspection  and  palpation  of  the  nares, 
will  establish  the  diagnosis. 

Fibrous,  sarcomatous,  and  cancerous  growths  in  the  nasal  cavity  are 
usually  of  deeper  color,  and  more  resistant  to  the  touch,  they  bleed 
easily,  and,  the  fibrous  growths  excepted,  have  a  more  irregular  sur- 
face than  polypi.  The  malignant  tumors  usually  grow  much  more 
rapidly,  often  causing  considerable  pain,  much  disfigurement,  and 
sooner  or  later  grave  constitutional  symptoms.  We  would  readily  de- 
tect cartilaginous  or  osseous  tumors  by  the  sense  of  touch. 

We  frequently  see  hypertrophy  of  the  mucous  membraiiQ  associated 
with  myxomata,  but,  on  the  other  hand,  the  mucous  polypi  may  cause 
atrophy  of  the  soft  tissues  and  sometimes  even  of  the  bony  structures. 

Prognosis. — The  affection,  if  not  relieved  by  operative  procedure, 
usually  continues  for  a  lifetime,  causing  the  patient  much  discomfort 
and  annoyance.  Although  the  obstructed  respiration  must  eventually 
compromise  the  general  health,  the  affection  does  not  appear  to  threaten 
life.  Often  the  tumors  remain  so  small  as  not  to  attract  the  patient's 
attention,  but  when  they  have  become  large  there  is  no  reason  to  ex- 
pert retrogression.  Spontaneous  expulsion  of  one  or  more  polypi  some- 
times occurs.  They  are  very  liable  to  recur  after  removal,  and  are 
sometimes  very  difficult  to  eradicate.  Rarely  myxomata  are  trans- 
formed into  sarcomata,  and  according  to  Schiffers,  of  Liege,  such  change 
occurs  only  in  subjects  past  the  fiftieth  year  (Transactions  Interna- 
tional Congress  Laryngology  and  Otology,  1889). 

Treatment. — For  destruction  of  the  growths  the  injection  of  vari- 
ous substances  has  been  recommended,  such  as  zinc  chloride,  iodine, 
alcohol,  carbolic  acid,  and  solution  of  iron  perchloride;  also  local  appli- 
cations of  saturated  watery  solutions  of  potassium  bichromate.  F.  Don- 
aldson, of  Baltimore,  has  also  recommended  introduction  into  the  tumor 
of  chromic  acid  on  a  sharp  pointed  probe.  While  these  methods  have 
sometimes  succeeded,  they  certainly  generally  fail,  even  in  the  hands  of 
skilful  operators. 

Evulsion  with  the  forceps,  the  oldest  method,  is  still  most  com- 
monly practised  by  general  surgeons,  though  seldom  employed  by 
laryngologists.  Sometimes,  however,  the  polypus  forceps  will  be  found 
useful.  As  commonly  performed  by  surgeons,  this  operation  is  very 
painful,  there  is  much  bleeding,  often  some  of  the  turbinated  bones  are 
torn  away  at  the  same  time,  and  rarely  are  the  polypi  completely  re- 
moved. Some  surgeons  advise  that  the  nose  be  laid  open  and  the  parts 
thoroughly  curetted.  This  would  evidently  be  more  effectual  than  re- 
moval with  forceps  in  the  old  way.  but  it  cannot  be  more  thorough  than 
removal  with  the  snare,  followed  by  cauterization  (or,  if  the  operator 
prefer,  curetting),  when   done  under  good  rhinoscopic  illumination,  by 


NASAL  MUCOUS  POLYPI. 


567 


which  every  part  can  be  seen  quite  as  well  as  if  the  nose  had  been  laid 
open.  Sometimes  polypi  may  be  cut  off  with  forceps  or  scissors.  The 
galvano-cautery  ecraseur  (Fig.  207)  affords  the  advantage  of  searing  the 
base  and  thus  destroying  it  at  the  time  when  the  tumor  is  cut  off,  but 
it  is  a  clumsy  instrument  compared  with  the  ordinary  steel-wire  snare 
which  is  the  one  now  generally  adopted  by  laryngologists.     When  polypi 


Fig.  207. — Galvano-Cautery  Handle,  with  Ecraseur  Attachment  (14  size). 

bud  again  after  removal,  the  best  treatment  is  thorough  searing  with 
the  galvano-cautery  while  they  are  still  small.  The  operation  which 
I  have  found  most  satisfactory  for  the  majority  of  cases  is  done  with 
the  steel-wire  ecraseur  or  snare  (Fig.  208).  This  is  a  modification  of  the 
snare  devised  by  Clarence  Blake,  of  Boston.  Good  instruments  for  the 
same  purpose  have  been  devised  by  Jarvis  and  Sajous,  and  various  modi- 
fications of  these  have  been  made  by  other  laryngologists. 

The  snare  is  armed  with  No.  5  steel  piano  wire,  which  in  practice 
has  been  found  to  answer  much  better  than  other  sizes.  The  loop  is 
passed  in  vertically,  its  under  edge  turned  beneath  the  polypus,  and 
then  with  a  backward  and  forward  movement  it  is  worked  up  as  near 
the  pedicle  as  possible.  The  loop  is  now  tightened,  and,  if  thought  best, 
the  polypus  cut  off  at  once,  but  usually  better  results  are  obtained  if  it 
is  torn  from  its  base  by  traction.     There  is  little  danger  in  this  way  of 


Fig.  208.— Ingals'  Snare,  with  Extra  Tubes  04,  size,  angle  25°). 

removing  any  of  the  normal  tissues,  for  it  is  almost  impossible  to  in- 
clude within  the  snare  anything  but  the  polypus.  Where  polypi  grow 
from  broad  bases,  and  are  attached  over  the  whole  surface  of  a  tur- 
binated body,  the  bone  may  be  torn  off  with  the  snare  if  much  traction 
is  made.  Under  such  circumstances  the  experienced  operator,  noticing 
the  increased  resistance  of  the  normal  tissue,  instead  of  continuing 
the  traction,  will  tighten  the  screw  and  cut  the  growth  as  near  its  base 
as  possible.  Where  polypi  grow  from  a  large  surface  of  the  turbinated 
body,  it  is  sometimes  better  to  remove  the  bone  to  prevent  recurrence. 
The  operator  should  have  at  hand  forty  or  fifty  applicators  (Fig. 


568  DISEASES  OF  THE  NASAL   CAVITIES. 

209),  wound  with  absorbent  cotton,  for  swabbing  out  the  blood  while  the 
operation  proceed.?,  as  it  is  useless  to  try  to  catch  the  tumors  when 
the  nose  is  rilled  with  blood.  Whatever  operation  is  performed,  the 
parts  should  first  be  thoroughly  anaesthetized  with  a  four  to  ten  per 
cent  solution  of  cocaine,  which  is  best  applied  by  means  of  a  hypoder- 
mic syringe  fitted  with  a  long,  blunt  silver  nozzle  (Fig.  210)  bent  at  the 
end  so  that  the  solution  may  be   thrown   up   about  the   base  of  the 


Fig.  209. — Cotton  Applicator  (2-6  size).    Made  of  copper. 

tumors.  Sometimes  both  cavities  may  be  cleared  at  once,  but  it  is 
usually  preferable  to  remove  what  growths  may  be  easily  reached, 
and  to  complete  the  operation  at  one  or  two  subsequent  sittings,  as 
this  generally  gives  the  patient  much  less  discomfort  than  one  long 
sitting.  It  will  be  remembered  that  the  effects  of  cocaine  disappear 
in  about  ten  minutes,  and  after  blood  has  once  begun  to  flow  it  is 
difficult  to  anaesthetize  the  parts  again;  furthermore,  if  too  much 
cocaine  is  used,  its  constitutional  effects,  even  if  not  alarming,  are  ex- 
tremely annoying.  After  the  polypi  have  been  removed,  the  patient 
should  cleanse  the  nose  once  or  twice  daily  with  the  salicylate  wash 
(Form.  1ST),  or  with  a  wash  of  sodium  bicarbonate,  a  teaspoonful  to  the 
pint  of  lukewarm  water. 

Antisepsis  and  healing  will  be  promoted  by  insufflation  two  or  three 
times  daily  of  a  powder  containing  twenty  per  cent  of  boric  acid,  fifty 
per  cent  of  iodol,  and  sugar  of  milk  sufficient  to  complete  the  mixture; 
together  with  the  use  of  a  spray  containing  about  one  minim  of  oil  of 
wintergreen,  two  minims  of  carbolic  acid,  three  minims  of  oil  of  cloves 


Fig.  210.— Hypodermic  Syringe  (^  siz»0.     L<  m^  silver  nozzle. 


to  an  ounce  of  liquid  albolene.  If  secretion  is  profuse,  ten  minims  of 
terebene  may  be  added  advantageously.  The  patient  should  return  in 
about  a  week,  when  it  will  often  be  found  that  sacs  which  were  invisible 
at  the  time  of  operation  have  rilled,  and  may  be  removed.  He  should 
return  again  in  four  or  six  weeks,  so  that  if  the  polypi  are  growing  they 
may  be  thoroughly  cauterized  with  the  galvano-cautery.  If  the  sur- 
geon is  not  provided  with  this  instrument,  chromic  acid  may  be  used 
instead.  In  some  cases  mucous  polypi  do  not  return  after  thorough 
removal,  but  usually  recurrence  takes  place,  and  operative  procedures 
must  be  repeated  from  time  to  time  until  complete  destruction  of  the 
growths  is  effected. 


ITASAL  PAPILLARY  TUMORS.  oii'.J 

NASAL  FIBROUS   POLYPI. 

Synonym. — Fibromata  of  the  nares. 

Fibrous  polypi  are  extremely  rare  in  the  nares,  although  not  uncom- 
mon in  the  naso-pharynx.  Generally,  growths  in  the  nasal  cavity  which 
resemble  fibrous  tumors  in  appearance  really  occupy  a  histological  posi- 
tion midway  between  mucous  and  fibrous  polypi,  termed  fibro-mucous. 
These  growths  differ  from  mucous  polypi  in  being  harder  and  bleed- 
ing more  easily.  They  should  be  removed,  when  possible,  by  the  natu- 
ral passages,  with  cutting  forceps,  snare,  or  galvano-cautery  ecraseur. 
The  latter  is  best  when  it  can  be  accurately  applied. 


NASAL   PAPILLARY  TUMORS. 

Synonym. — Papillomata  of  the  nares. 

Nasal  papillary  tumors,  though  occurring  more  frequently  than 
fibrous  polypi,  are  still  infrequent,  though  Hopmann  states  that  small 
warty  growths  are  more  common  than  generally  supposed,  and  he  has 
met  with  numerous  cases  (Virchow's  Archiv,  Band  XCIII,  1883).  He 
also  states  that  Schaffer,  of  Bremen,  lias  observed  them  quite  as  fre- 
quently. This  is  different  from  the  observations  of  Mackenzie,  Zuc- 
kerkandl,  and  various  other  laryngologists,  and  from  my  own  expe- 
rience. 

Anatomical  and  Pathological  Characteristics. — The  true  pa- 
pillary or  warty  growths  are  stated  by  Hopmann  to  spring  invariably  from 
the  lower  turbinated  body,  though  I  have  seen  one  such  tumor  growing 
from  the  septum  alone,  and  another  instance  in  which  several  of  these 
tumors  grew  from  the  septum  while  others  came  from  the  turbinated 
body  directly  opposite.  They  vary  in  size  from  two  to  fifteen  milli- 
metres in  diameter.  In  five  cases  observed  by  Mackenzie,  the  tumors 
"were  situated  on  the  septum  or  on  tbe  inner  plate  of  the  alar  cartilage. 

Symptomatology. — The  symptoms  which  I  have  observed  were  those 
referable  to  dry  catarrh,  with  the  usual  signs  of  obstruction  of  the  nasal 
passage  when  the  tumor  was  large.  Hopmann  also  observed  frequent 
cough  and  expectoration,  which  he  attributed  to  the  papillary  growths. 

Diagnosis. — The  diagnosis  must  be  based  upon  the  peculiar  appear- 
ance of  the  growths,  which,  unless  they  are  moistened  by  secretion,  is 
similar  to  that  of  warts  upon  the  integument,  and  upon  microscopic 
examination,  which  will  determine  their  papillary  character. 

Prognosis. — The  tumors  tend  to  increase  in  number,  and  are  very 
apt  to  recur  when  removed. 

Treatment. — The  growth  may  be  destroyed  with  nitric,  acetic,  or 
chromic  acid,  the  cutting  forceps  or  curette,  or  the  galvano-cautery. 
In  one  obstinate  case  under  my  care,  all  of  these  methods  were  tried 


570  DISEASES  OE  THE  NASAL   (J A  YITIES. 

unsuccessfully;  the  warts  repeatedly  returned  again  in  four  to  six  weeks 
after  each  removal.  Finally  the  patient  was  given  a  strong  tincture  of 
thuja  occidentalism  which  he  applied  to  the  part  two  or  three  times  daily. 
This,  with  a  few  applications  of  chromic  acid,  finally  eradicated  the 
disease. 

NASAL    VASCULAR  TUMORS. 

Synonym. — Angiomata  of  the  nose. 

Vascular  tumors  in  the  nose  are  extremely  rare.  In  their  removal, 
Jarvis,  who  judges  from  his  own  experience  and  a  tabulated  report 
of  sixteen  cases  by  J.  0.  Roe,  of  Rochester  {New  York  Medical  Journal, 
January,  1886),  considers  the  cold-wire  snare  safer,  simpler,  and  more 
satisfactory  than  the  galvano-cautery  or  other  agents  (International  Jour- 
nal of  Surgery  and  Antiseptics,  1889).  In  one  successful  case  reported 
by  him,  the  gradual  removal  occupied  three  hours  and  there  was  no 
hemorrhage.  Reasoning  from  analogy  only,  the  galvano-cautery  would 
appear  to  be  the  best  instrument  in  such  cases. 


NASAL  OSSEOUS   CYSTS. 

Osseous  cysts  of  the  middle  turbinated  body  have  recently  been  the 
subject  of  articles  by  H.  Zwillinger,  of  Budapest,  Charles  H.  Knight,  of 
Isew  York,  and  Greville  Macdonald,  of  London. 

This  variety  of  tumor  is  rare,  and  its  etiology,  pathology,  and 
symptomatology  are  not  yet  fully  understood.  Charles  E.  Sajous 
(Annual  of  the  Universal  Medical  Sciences,  1892)  quotes  Macdonald  as 
follows:  "Whenever  an  osseous  tumor  presents  itself  in  the  middle 
meatus  of  such  a  size  that  it  is  obviously  something  further  than  a  simple 
osteophytic  periostitis,  whether  presenting  an  osseous  surface  covered 
only  by  mucous  membrane  or  whether  it  is  concealed  partially  or  entirely 
by  polypoid  growths,  the  probability  is  strongly  in  favor  of  cyst.  When, 
moreover,  these  appearances  are  accompanied  by  a  purulent  and  fetid 
discharge,  one  may  safely  surmise  that  he  is  dealing  with  a  suppurating 
cyst  or  abscess  of  the  middle  turbinate.  The  diagnosis  is  finally  substan- 
tiated by  the  removal  of  a  portion  of  the  walls  of  the  tumor  by  snare  or 
forceps. 

"  The  treatment  is  simple  enough  in  cases  when  the  tumor  has  not 
attained  enormous  dimensions.  The  simplest  way  of  effecting  removal 
is  to  throw  a  strong  snare  around  the  mass  and  remove  as  large  a  portion 
as  possible.  The  remaining  portion  of  the  walls  may  afterward  be  broken 
away  with  forceps." 

I  have  seen  but  a  single  case  of  the  kind,  which  was  easily  removed 
with  snare  and  forceps.  The  cyst  was  filled  with  a  soft,  yellowish  cheesy 
mass. 


NASAL  BONY  TUMORS.  571 


NASAL   CARTILAGINOUS  TUMORS. 

Synonym. — Ecchondromata  of  the  nose. 

True  cartilaginous  tumors  in  the  nasal  cavities  are  extremely  rare, 
though  a  few  cases  have  been  reported.  Ecchondroses  or  cartilaginous 
outgrowths,  however,  are  very  common,  and  will  be  considered  else- 
where. 

Anatomical  and  Pathological  Characteristics. — Cartilaginous 
tumors  closely  resemble  fibrous  polypi;  they  are,  however,  sessile,  gen- 
erally grow  from  the  cartilaginous  septum,  and  if  not  interfered  with 
may  attain  an  enormous  size,  causing  great  deformity  of  the  face. 

Symptomatology. — The  symptoms  are  those  of  nasal  obstruction. 

Diagnosis. — The  cartilaginous  growths,  when  large,  are  liable  to  be 
mistaken  for  fibrous  polypi,  malignant  growths,  exostoses,  or  osteomata. 
Practically  we  may  exclude  fibromata,  because  of  their  rarity.  When 
present,  they  bleed  more  easily  and  are  less  dense  than  cartilaginous 
growths.  It  is  to  be  observed  that  malignant  tumors  are  softer,  bleed 
easily,  and  grow  rapidly.  We  readily  distinguish  exostoses  and  ecchon- 
droses by  inspection  as  being  simple  outgrowths.  It  is  distinctive  that 
bony  tumors  are  harder  and  cannot  be  penetrated  by  the  needle  like  car- 
tilaginous growths. 

Prognosis. — The  prognosis  is  favorable  if  the  disease  is  detected 
early,  before  great  deformity  has  occurred.  There  is  no  tendency  to 
recurrence  when  the  tumor  has  been  removed. 

Treatment. — Removal  by  galvano-cautery  ecraseur  is  the  most  sat- 
isfactory surgical  operation. 

NASAL  BONY  TUMORS. 

^wowz/m.— Osteomata  of  the  nose. 

Nasal  bony  tumors  are  usually  characterized  by  obstruction  of  the 
nasal  passage  and  severe  neuralgic  pains.  When  occurring,  they  usually 
develop  about  the  age  of  puberty,  but  they  are  rare. 

Anatomical  and  Pathological  Characteristics. — Osteomata 
are  usually  ovoid  in  form,  and  they  vary  in  diameter  from  five  millime- 
tres to  five  centimetres.  They  are  distinctly  bony  formations,  some- 
times exceedingly  dense,  yet  at  others  cancellous;  but  they  have  little 
or  no  connection  with  the  osseous  structure  of  the  nose,  and  are  gener- 
ally attached  to  the  soft  tissues  by  a  comparatively  small  pedicle.  They 
are  covered  by  periosteum  and  mucous  membrane,  which  is  freely  sup- 
plied with  blood  vessels  and  of  a  pink  or  red  color,  and  is  occasionally 
ulcerated  from  pressure. 

Etiology. — The  etiology  is  unknown. 

Symptomatology.— Early,  the  bony  growth  commonly  causes  intol- 


573  DISEASES   OF   THE  NASAL   CAVITIES. 

erable  itching  of  the  nose,  which  is  soon  followed  by  symptoms  of  ob- 
struction, with  impairment  of  the  sense  of  smell,  and  frequent  epistaxis. 
As  it  begins  to  press  upon  the  surrounding  parts,  neuralgic  pains  some- 
times become  extremely  severe.  In  some  instances,  however,  the  nerves 
of  sensation  are  paralyzed,  and  no  suffering  is  experienced.  As  the 
growth  enlarges,  the  nose  may  be  distorted,  the  cheek  may  become 
prominent,  and  the  eyeball  crowded  outward.  In  some  cases  con- 
tinued pressure  causes  ulceration  and  finally  perforation  of  the  exter- 
nal parts.  Such  tumors  are  usually  attended  by  an  offensive  discharge. 
By  inspection  the  tumor  may  be  seen.  Its  densitv  or  immovability  ran 
be  ascertained  with  the  needle  or  probe. 

Diagnosis. — The  bony  growths  may  be  confounded  with  exostoses, 
rhinoliths,  or  cancer.  They  may  be  distinguished  from  exostoses  at  the 
outset  by  their  movability,  and  later  by  their  different  form,  larger  size, 
and  darker  color.  We  can  distinguish  rhinoliths  by  an  absence  of 
mucous  covering,  and  by  the  ease  with  which  the  surface  is  broken 
or  crumbled  by  a  strong  nasal  probe  or  forceps.  It  has  been  found  that 
cancerous  tumors  grow  much  more  rapidly  and  are  usually  very  soft. 
In  all  cases  they  may  be  easily  punctured  by  the  needle.  They,  like 
osteomata,  cause  extreme  pain  and  an  offensive  discharge. 

Prognosis. — If  the  tumor  is  seen  early  enough,  it  may  be  readily  re- 
moved through  the  natural  passages,  but,  when  large,  external  incisions 
are  necessary  and  scars  remain,  unless  it  can  be  destroyed  by  a  dental 
burr.     There  is  no  tendency  to  recurrence. 

Treatment. — The  softer  forms  may  be  crushed  with  strong  forceps 
and  the  fragments  easily  removed,  but  in  the  hard  variety,  which  is 
most  frequent,  this  is  difficult,  if  not  impossible.  If  not  too  large,  they 
may  be  ground  down  or  drilled  through  with  dental  burrs  or  trephines, 
and  subsequently  broken,  but,  if  very  large,  an  external  incision  is 
usually  necessary  for  their  removal. 

NASAL  MALIGN  AS  T   TUMORS. 

Cancerous  growths  of  the  nose  are  characterized  by  rapid  growth, 
obstruction  of  the  nasal  cavities,  an  offensive  discharge,  frequent  epi- 
staxis, and  usually  by  severe  pain. 

Anatomical  and  Pathological  Characteristics. — They  com- 
monly grow  from  the  septum,  but  sometimes  from  the  outer  wall  or 
floor  of  the  nasal  cavity.  They  are  usually  sarcomatous,  but  sometimes 
carcinomatous.  They  tend  to  increase  rapidly  in  size,  and  soon  en- 
croach upon  surrounding  structures.  They  have  a  pale,  slightly 
nodular  or  raspberry-like  surface,  are  of  soft  consistence  as  a  rule.,  and 
bleed  freely  when  touched  with  the  probe;  their  microscopic  character- 
istics are  the  same  as  those  of  similar  growths  in  other  parts  of  the 
body. 


NASAL  MALIGNANT  TUMORS.  573 

Etiology. — The  etiology  is  unknown. 

Symptomatology. — At  first  there  are  alteration  of  the  voice,  impair- 
ment of  the  sense  of  smell,  and  sensations  of  stuffiness  in  the  nose  com- 
mon to  all  tumors  in  this  locality.  Other  symptoms,  however,  rapidly 
develop.  A  greenish,  offensive  discharge  is  apt  to  soon  occur,  frequent 
epistaxis  takes  place,  and  great  pain  is  often  felt  in  the  infra-orbital 
region.  As  the  disease  progresses,  the  bony  structures  are  pushed  in 
front  of  it  or  separated  from  each  other,  the  eyeball  protrudes,  and 
the  mass,  perforating  the  base  of  the  skull,  may  extend  to  the  brain. 
Deafness,  dysphagia,  and  dyspnoea  are  all  symptoms  which  may  occur  in 
the  progress  of  the  case,  and  ere  long  constitutional  symptoms  appear 
indicated  by  loss  of  appetite,  the  development  of  fever,  and  a  marked 
cachexia.  Upon  inspection,  a  tumor  may  be  detected,  usually  of  a  light 
pink  hue,  but  sometimes  darker,  even  brown  or  black;  highly  vascular, 
bleeding  easily  when  touched,  and  commonly  soft  and  friable.  Malig- 
nant growths  ulcerate  early;  the  ulcer  presenting  raised,  ragged  edges, 
and  a  sanious  base. 

Diagnosis.— Malignant  tumors  of  the  nose  are  to  be  distinguished 
from  rhinoliths,  impacted  foreign  bodies,  abscess,  and  benign  growths. 
When  the  nasal  cavity  has  been  cleansed  and  well  illuminated,  we  find 
the  appearance  of  a  rliinolitli  or  impacted  foreign  body,  and  the  sensa- 
tion it  communicates  through  the  probe  entirely  different  from  that  of 
a  malignant  tumor.  An  abscess  may  be  developed  rapidly  or  slowly, 
but  it  is  almost  universally  located  at  the  lower  part  of  the  septum,  is 
apt  to  present  upon  both  sides,  is  covered  by  normal  mucous  membrane, 
does  not  bleed,  is  elastic  to  the  touch,  and  is  not  attended  by  the  symp- 
toms so  commonly  found  in  malignant  growths.  We  may  distinguish 
benign  tumors  by  their  color,  density,  slow  growth,  and  other  symptoms 
already  described.  In  malignant  growths,  after  a  short  time  there  is  an 
enlargement  of  the  lymphatics,  especially  those  below  the  angle  of  the 
jaw.     This  does  not  occur  witb  benign  tumors. 

Prognosis. — The  disease  usually  runs  a  rapid  course,  terminating 
within  six  or  eight  months  in  death.  Sarcomata  appear  to  have  been 
eradicated  in  some  cases  where  taken  early,  but  carcinomata  are  always 
fatal. 

Treatment. — Astringents  and  sedatives  may  be  applied  as  palliative 
measures,  but  thorough  eradication,  when  practicable,  is  the  only  treat- 
ment that  affords  any  chance  of  success.  Partial  removal  only  aggra- 
vates the  disease  and  causes  its  more  rapid  growth. 

E.  P.  Lincoln  reports  a  case  of  melano-sarcoma  of  the  lower  and 
middle  turbinated  bones  and  floor  of  the  nostril  which,  returning  after 
several  operative  procedures,  was  finally  completely  cured  by  the  use  of 
the  galvano-cautery  ecraseur  with  cauterization  at  the  site  of  removal 
(Transactions  of  the  American  Laryngological  Association,  1885). 


CHAPTEK    XXXIV. 

DISEASES  OF   THE   NASAL  CAVITIES.— Continued. 

SYPHILIS  OF  THE  NOSE. 

A  local  manifestation  of  constitutional  syphilis  in  the  nose  may  be 
primary,  secondary,  or  tertiary,  and  may  be  congenital  or  acquired.  It  is 
characterized  in  mild  cases  by  simple  obstruction  of  the  nares,  and  in 
the  more  severe  by  extensive  ulceration  and  necrosis  of  the  bones  and 
cartilages. 

Anatomical  and  Pathological  Characteristics. — The  mucous 
membrane  may  be  thickened  in  patches  or  may  be  ulcerated.  Condylo- 
mata are  sometimes  observed,  and  if  the  perichondrium  or  periosteum 
beneath  the  thickened  patches  becomes  the  seat  of  suppuration,  death  of 
the  cartilage  or  bone  is  the  natural  result.  This  necrosis  may  also  fol- 
low extension  of  the  ulceration  from  the  surface.  Sometimes  the  pro- 
cess is  one  of  gradual  molecular  destruction  or  slow  caries,  entirely  es- 
caping observation  during  life.  In  such  cases  the  bone,  gradually 
devitalized  and  absorbed,  is  replaced  by  exuberant  granulations. 

Etiology. — The  sole  cause  is  the  syphilitic  virus,  but  the  severity 
of  the  disease  often  appears  to  depend  upon  individual  constitutional 
peculiarities  other  than  syphilitic.  According  to  Mackenzie,  the  stru- 
mous diathesis  seems  to  render  the  subject  particularly  liable  to  severe 
forms  of  nasal  syphilis;  and  in  countries  where  the  disease  is  imper- 
fectly treated,  as,  for  example,  in  Egypt  and  Mexico,  it  becomes  virulent. 
Primary  syphilis  of  the  nose  is  very  rare.  The  secondary  form  is  not ' 
infrequent  in  infants,  in  whom  it  is  usually  developed  about  the  third 
or  fourth  month;  but  it  is  generally  overlooked,  and  passes  for  what  the 
nurse  terms  snuffles.  Tertiary  manifestations  are  seldom  noticed 
until  several  years  after  the  initial  lesion;  but  the  symptoms  are  some- 
times developed  between  the  sixth  and  twelfth  month,  and  it  is  stated 
that  among  the  modern  Arabs,  where  syphilis  is  peculiarly  severe,  the 
tertiary  symptoms  appear  much  earlier. 

In  the  secondary  stage  of  the  disease,  the  congestion  of  the  mucous 
membrane  causes  profuse  muco-purulent  secretion  and  more  or  less 
obstruction  of  the  nares.  Mucous  patches  may  occasionally  be  observed 
at  the  angle  of  the  nostrils  or  upon  the  anterior  portion  of  the  mucous 
membrane.  Evidences  of  the  disease  in  the  mouth  and  throat  and  upon 
the  skin  are  usually  present  at  the  same  time.     In  the  tertiary  stage, 


SYPHILIS  OF  THE  NOSE.  575 

there  occurs  necrosis  of  the  cartilaginous  or  bony  septum  or  of  the  tur- 
binated bodies,  accompanied  by  a  most  offensive  odor  of  decaying  tissue. 

Extensive  destruction  of  the  nasal  bones  causes  falling  in  of  the 
bridge  of  the  nose,  and  the  oral  cavity  may  be  entered  by  perforation  of 
the  palate.  Deep,  foul  ulcers,  with  ragged  edges  and  a  dirty,  gray  base, 
are  usually  present.  Before  extensive  destruction  has  taken  place,  the 
turbinated  bodies  are  often  so  swollen  as  nearly  or  quite  to  occlude  the 
nares.  The  dead  bone  usually  presents  a  blackish,  uneven  surface, 
though  in  some  instances  nothing  can  be  seen  except  an  offensive  crust 
of  dried  and  decaying  secretion,  which  must  be  thoroughly  washed  away 
before  satisfactory  examination  can  be  made;  it  can  sometimes  be  de- 
tected with  a  probe,  by  the  rough,  grating  sensation  which  it  com- 
municates; occasionally  the  lesions  are  so  situated  that  they  cannot  be 
discovered.  In  rare  instances  an  offensive  odor  is  constantly  exhaled, 
even  though  the  parts  are  apparently  kept  perfectly  cleansed  by  fre- 
quent ablutions. 

Diagnosis. — The  secondary  stage  of  the  disease  is  not  common, 
and,  when  it  does  occur,  is  very  apt  to  escape  observation.  It  can 
be  distinguished  from  chronic  rhinitis  by  the  history  of  its  sudden 
onset  with  very  pronounced  symptoms;  by  its  very  obstinate  course; 
by  the  discovery  of  mucous  patches  or  condylomata  when  these  exist; 
and  by  the  acknowledgment  of  infection  when  this  can  be  obtained 
from  the  patient.  The  tertiary  affection  may  be  confounded  with  lupus 
or  simple  atrophic  rhinitis.  We  can  distinguish  lupus  from  syphilis  by 
its  occurring  at  an  earlier  age  than  any  form  of  syphilis  except  the 
hereditary.  Again,  in  the  beginning,  the  peculiar  reddish  papules  or 
tubercles  of  lupus  are  quite  distinct  from  any  syphilitic  manifestations; 
and,  later,  the  marked  preference  which  lupus  shows  for  the  cartilage  is 
characteristic. 

The  offensive  odor  caused  by  atrophic  rhinitis  is  quite  different  from 
the  stench  of  tertiary  syphilis.  Upon  cleansing  the  parts  carefully,  no 
necrosed  tissue  will  be  found  in  ozama,  whereas  it  is  very  apt  to  be 
present  in  syphilis.  In  all  doubtful  cases,  the  history,  the  presence  of 
old  cicatrices,  or  induration  of  the  tongue,  pharynx,  or  larynx,  or  brown- 
ish scars  upon  the  skin  or  periosteal  nodes,  and  finally  the  beneficial 
action  of  potassium  iodide  usually  enable  us  to  make  a  diagnosis  of 
syphilis. 

Pkognosis. — Syphilitic  coryza  in  the  adult  usually  terminates  within 
two  or  three  weeks.  Secondary  symptoms  and  those  of  the  tertiary 
stage  in  mild  cases,  as  a  rule,  speedily  disappear  under  proper  anti- 
syphilitic  treatment.  When  caries  has  taken  place,  and  is  still  pro- 
gressing, the  prognosis  is  much  less  favorable,  especially  in  debilitated 
subjects,  in  whom  even  life  may  be  endangered. 

Teeatment. — Syphilitic  coryza  requires  no  other  treatment  than 
the  internal  administration  of  tonics,  and  the  local  use  of  mild  alkaline 


r>  7 I '-  DISEA  SE8  OF  THE  XA  SA  L   <  'A  T  'ITIES. 

sprays  or  washes.  Indeed,  any  secondary  symptoms  usually  require  only 
mild  constitutional  treatment,  and  touching  of  the  condylomatous 
growths  or  mucous  patches  with  tincture  of  iodine  or  silver  nitrate. 
Tertiary  syphilis,  however,  demands  active  constitutional  and  local 
treatment.  It  is  well  to  begin  with  potassium  iodide  in  moderate 
quantity,  and  steadily  increase  the  doses  until  the  reparative  process 
is  well  established.  To  this  end,  7iot  infrequently  the  drug  must 
be  pushed  to  its  physiological  limit.  In  all  cases  it  or  other 
specific  medication  should  be  continued  in  larger  or  smaller  doses 
until  a  complete  cure  is  effected.  Small  doses  of  mercur}',  or  of 
gold  and  sodium  chlcride,  will  sometimes  be  found  especially  bene- 
ficial. At  the  same  time,  bitter  or  ferruginous  tonics  are  often  de- 
manded, and  cod-liver  oil  when  well  borne  is  useful.  Good  nutri- 
tious diet  should  be  provided.  Local  treatment  is  extremely  impor- 
tant. The  nose  should  be  thoroughly  cleansed  two  or  three  times  daily 
with  the    sodium    salicylate   wash   (Form.   18?)   or   a   similar  alkaline 


Fig.  211.— Ingals'  Nasal  Dressing-Forceps  (3-5  size). 

solution.  Under  this  treatment  superficial  ulcers  usually  speedily  heal; 
but  where  deep  ulceration  exists,  in  addition  to  cleansing,  the  sores 
must  be  touched  with  some  stimulant  or  caustic.  For  this  purpose  the 
most  commonly  employed  caustic  is  silver  nitrate  fused  upon  the  end  of 
an  aluminium  or  silver  applicator,  but  in  the  majority  of  cases  '  prefer 
strong  tincture  of  iodine  to  any  other  local  remedy.  The  applications 
should  be  made  daily  for  ten  or  fourteen  days,  until  evidence  of  cica- 
trization appears,  and  then  every  other  day  for  a  week  or  more,  and 
subsequently  less  often.  Even  large  ulcers  under  this  treatment  usually 
heal- within  three  or  four  weeks.  If  dead  bone  is  present,  it  must  be 
carefully  removed  with  forceps  (Fig.  211),  though  it  is  unsafe  to  use 
much  force.  In  the  mean  time  the  patient  may  advantageously  insuf- 
flate into  the  nasal  cavity  twice  daily  a  powder  consisting  of  one  part 
boric  acid  and  two  parts  iodol  or  iodoform;  or  with  this,  in  case  there  is 
much  swelling,  may  be  combined  two  or  three  per  cent  of  cocaine,  and 
five  per  cent  of  aristol  to  correct  the  offensive  odor.  Schuster  specially 
recommends  scraping  the  ulcers  with  a  sharp  spoon,  and  afterward  de- 
stroying any  indurated  tissue  that  may  remain  with  the  galvano-cautery 
or  silver  nitrate  (Viertetyahresschrift  fur  Dermatologie  r.  Syphilis,  1877). 


CONGENITAL  SYPHILIS  OF  THE  NOSE.  577 

When  the  disease  has  been  checked,  if  serious  deformity  exists,  it  may 
sometimes  be  remedied  by  an  artificial  nose,  or  in  some  cases  by  rhino- 
plastic  operations,  which  are  described  in  the  textbooks  of  surgery. 

CONGENITAL    SYPHILIS    OF   THE   NOSE. 

Hereditary  syphilis  usually  makes  its  appearance  in  children  within 
the  first  two  or  three  weeks  after  birth,  and  seldom  later  than  the 
second  month;  but  occasionally  not  until  the  child  is  eight  or  ten  years 
of  age,  or  at  a  later  period,  about  puberty. 

Etiology. — The  disease  appears  to  be  contracted,  in  many  instances, 
at  the  time  of  birth,  though  commonly  during  intra-uterine  life. 

Symptomatology. — Usually  within  a  week  or  two  after  birth  the 
child  appears  to  have  a  bad  cold  in  the  head,  the  nares  are  stopped, 
and  there  appears  a  thin,  irritating  discharge,  which  soon  becomes 
muco-purulent,  causing  redness,  soreness,  and  erosion  of  the  nostrils  and 
upper  lip.  The  child  is  said  to  have  the  snuffles.  As  the  secretions 
become  thicker,  the  nasal  cavity  is  blocked  with  scabs,  which  exhale  an 
offensive  odor.  In  some  instances  caries  of  the  cartilages  and  bones 
ensues,  not  infrequently  causing  disfigurement  for  life.  Such  children 
are  usually  small  and  feeble,  suffer  from  marasmus,  and  frequently  have 
a  copper-colored,  papular  eruption  upon  the  skin.  Mucous  patches  are 
probably  present  in  the  nose  in  most  cases,  but  it  is  hard  to  get  a  view 
of  them;  similar  patches  may  often  be  found  at  the  anus  or  at  the 
angles  of  the  mouth  or  eyelids. 

Diagnosis. — The  diagnosis  must  depend  upon  the  history,  the 
symptoms,  the  obstinacy  of  the  disease,  and  the  effects  of  treatment. 

Prognosis.— The  affection  runs  a  chronic  course,  with  little  or  no 
tendency  to  spontaneous  recovery.  Such  children  often  die  young;  but 
under  judicious  treatment  some  may  be  apparently  cured.  In  a  con- 
siderable number  the  disorder  may  be  checked,  but  it  continues  to  re- 
appear at  intervals  for  many  years. 

Treatment. — Mercurials  and  potassium  iodide  are  indicated  inter- 
nally, and  local  treatment  is  generally  desirable,  though  in  young  chil- 
dren it  is  very  difficult  to  carry  out.  Mackenzie  prefers  mercury 
with  chalk,  which  he  administers  in  doses  of  from  one  to  two  grains 
twice   daily,   to  which  he  adds,  if  this  causes  diarrhcea,  one  grain  of 

Dover's  powder  or  an  additional  grain  of  chalk  (Diseases  of  the 
Throat  and  Nose,  Vol.  II).  Eriehsen  recommends  the  external  applica- 
tion of  mercury  in  the  following  manner  proposed  by  Brodie  (Science 
and  Art  of  Surgery,  London,  1872):  a  drachm  of  mercurial  ointment  is 
spread  upon  a  flannel  roller  which  is  stretched  around  the  child's  thigh 
just  above  the  knee,  the  ointment  next  to  the  skin.  This  is  renewed 
daily  for  two  or  three  weeks,  after  which  potassium  iodide  is  adminis- 
tered in  milk,  cod-liver  oil,  or  malt.  Milk  and  water  are  the  best  vehicles 
for  the  administration  of  the  drug  to  either  children  or  adults. 
37 


578  DISEASES  OF  THE  NASAL   CAVITIES 


TUBERCULOSIS  OF  THE   NARES. 

Tuberculosis  of  the  nares  is  a  rare  affection  characterized  by  the  for- 
mation of  tubercles  of  varying  size,  with  ulceration  and  a  fetid  discharge. 
It  is  usually  secondary,  though  Tornwaldt  has  reported  a  case  in  which 
the  nasal  symptoms  preceded  any  other;  and  I  have  seen  one  case  in  which 
no  evidence  of  pulmonary  lesion  could  be  discovered  for  several  months 
after  the  appearance  of  the  tubercular  ulcer  in  the  nostril.  Of  thirty- 
eight  cases  of  nasal  tuberculosis  collected  by  Michelson,  of  Konigsberg, 
nineteen  showed  no  tuberculosis  of  any  other  organ  (Internationale 
Minische  Rundschau,  Vienna,  1889),  and  F.  Halm  reports  five  primary 
cases  (Deutsche  medicinische  Wochenschrift,  Leipsic,  1889). 

Anatomical  and  Pathological  Charactekistics. — The  tuber- 
cular deposit  may  be  observed  either  as  thickening,  with  or  without 
ulceration  of  the  mucous  membrane,  or  in  the  form  of  tumors  varying 
from  two  to  thirty  millimetres  in  diameter.  The  disease  may  attack 
any  part,  but  most  frequently  the  septum  is  the  seat  of  the  trouble. 
The  nodules  are  generally  small  and  of  a  grayish  white  color;  the  ulcers, 
which  may  be  single  or  multiple,  have  a  grayish  base  and  frequently 
raised  edges. 

Etiology. — The  bacillus  tuberculosis  is  now  generally  accepted  as 
the  ultimate  cause  of  the  disease. 

Symptomatology. — The  affection  comes  on  insidiously,  and  gener- 
ally progresses  slowly,  causing  all  the  symptoms  of  offensive  catarrh. 
Tubercles  or  ulcers,  as  already  described,  may  be  detected  by  careful 
inspection.  The  ulcers  are  not  generally  painful  und  at  first  are  not 
accompanied  by  constitutional  symptoms;  but  sooner  or  later  tubercu- 
losis of  the  lungs  or  larynx  is  developed,  and  runs  its  ordinary  course. 

Diagnosis. — Tuberculosis  may  always  be  suspected  when  obstinate 
ulcers  or  tubercles  are  detected  in  the  nose,  especially  in  scrofulous  pa- 
tients, or  those  with  recognized  tuberculosis  of  other  organs  providing 
syphilis  has  been  carefully  excluded.  An  accurate  diagnosis  can  only 
be  made  by  finding  tuberculosis  in  other  parts  or  by  the  detection  of  the 
bacillus  tuberculosis  in  the  discharges  or  scrapings  from  the  ulcers. 

Prognosis. — The  progress  of  the  disease  is  generally  slow,  and  may 
extend  over  many  years;  but  it  usually  continues  until  other  organs 
finally  become  involved,  and  then  runs  a  more  rapid  course  to  a  fatal 
termination. 

Treatment. — The  nares  should  be  kept  clean.  Tumors  which  by 
their  size  interfere  with  respiration  should  be  removed,  and  ulcers  should 
be  thoroughly  treated  with  lactic  acid,  in  strength  varying  from  thirty 
to  one  hundred  per  cent,  with  or  withoujt  previous  scraping,  according 
to  the  indications.  Treatment  of  the  ulcerated  surface  by  carefully 
touching  it  from  time  to  time  with  the  galvano-cautery  has  been  recom- 


EMPYEMA    OF  THE  ANTRUM. 


579 


mended,  and  is  advantageous  in  some  cases.  Insufflations  of  iodol  or 
iodoform  are  also  indicated;  but  whatever  method  is  adopted,  the 
ulcers  are  very  difficult  to  heal,  and  in  many  cases  the  treatment  does 
no  appreciable  good.  When  pain  is  present,  soothing  remedies  are 
required.  Of  prime  importance  are  all  those  means  by  which  the 
system  may  be  fortified  against  the  spread  of  the  disease.  It  would 
appear  that  these  cases,  if  any,  might  be  cured  by  the  use  of  Koch's 
tuberculin;  but  in  a  single  case  of  the  kind  in  which  I  administered  it, 
the  results  were  most  disastrous,  and  the  progress  of  the  disease  was 
yery  much  accelerated  by  the  presumed  remedy. 

EMPYEMA  OP  THE   ANTRUM. 

Empyema  of  the  antrum,  which  was  accurately  described  by  John 
Hunter,  consists  of  a  collection  of  pus  in  the  antrum  of  Highmore, 
characterized  by  a  purulent  discharge  having  an  offensive  odor,  usually 


Fig.  213. — Cross  Section  of  Head  Looking  prom  Behind  Forward  about  Half  an  Inch  in  Front 
•of  the  Opening  of  the  N  ares  into  the  Naso-Pharynx.  From  a  photograph  of  a  frozen  section 
prepared  by  C.  H.  Stowell,  of  Washington  (4-5  natural  size),  a.a.  Middle  turbinated  bodies;  b,b,  in- 
ferior turbinated  bodies;  c,c,c,c,  ethmoid  cells;  d,d,  antra  of  Highmore. 

from  one  nostril.  It  is  more  commonly  found  upon  the  left  side,  but 
frequently  upon  the  right,  and  occasionally  on  both  sides.  The  antrum, 
as  shown  by  Giraldes,  is  sometimes  divided  by  sejita  of  bone,  so  that  in 
this  disease  two  or  more  pockets  of  pus  may  exist  (Des  Maladies  du  Sinus 
Maxillaire,  Paris,  1857).  Delavan,  in  a  paper  read  before  the  American 
Medical  Association,  Section  of  Laryngology,  in  1889,  showed  that  the 
antra  are  liable  to  various  irregularities  in  formation,  which  accounts 
for  some  of  the  peculiarities  presented  in  the  symptoms  and  signs  of  the 
disease.  The  relations  of  these  cavities  to  the  nares  and  surrounding 
parts  are  accurately  shown  in  Fig.  79,  and  Fig.  212. 

Etiology. — Disease  of  the  teeth  is  the  principal  cause  of  the  affec- 
tion ;  but  in  many  instances  it  originates  in  morbid  changes  in  the  nasal 


580  DISEASES   <>F  THE  NASAL    CAVITIES. 

cavity  or  adjoining  sinuses,  such  as  caries,  polypi  or  granulation  tissue 
in  the  middle  meatus,  or  suppurative  inflammation  of  the  ethmoid  cells 
or  middle  meatus,  the  pus  from  which  enters  the  antrum. 

Symptomatology. — The  affection  usually  comes  on  insidiously  and 
lasts  for  several  months,  or  possibly  years,  before  it  is  detected.  When 
it  has  existed  for  some  time,  there  may  be  found  considerable  disturb- 
ance of  the  general  health.  In  most  cases,  pain  in  the  cheek  is  com- 
plained of,  sometimes  radiating  toward  the  ear  and  frequently  attended 
by  supra-orbital  neuralgia.  But  comparatively  few  of  the  patients  suf- 
fer from  toothache  or  swelling  of  the  face,  the  most  common  subjec- 
tive symptoms  being  more  or  less  obstruction  of  the  nose,  a  foul 
smell  or  taste  seemingly  from  the  throat,  and  discharge  from  one  nos- 
tril. The  fetor  is  often  appreciated  only  by  the  patient  himself,  and 
is  present  in  many  instances  only  at  certain  hours  of  the  day.  The  dis- 
charge also  is  usually  periodical,  occurring  in  considerable  quantities 
two  or  three  times  a  day,  though  in  many  instances  there  is  a  continual 
but  slight  flux.  Sometimes  this  is  only  experienced  upon  assuming  cer- 
tain positions,  as  when  lying  upon  the  affected  side,  or  even  upon  the 
sound  side,  or,  again,  upon  bending  forward  with  the  head  low  down. 
Sometimes  the  principal  flow  is  into  the  naso-pharynx,  where  it  may 
excite  reflex  cough,  or  even  nausea  and  vomiting.  Upon  inspecting  the 
nares,  a  jmrulent  discharge  is  generally  observed  in  the  middle  meatus, 
trickling  down  over  the  inferior  turbinated  body.  Oftentimes  this,  on 
being  wiped  away,  speedily  reappears.  Polypi  or  granulation  tissue  may 
be  seen  in  a  large  percentage  of  cases,  and  with  the  probe  caries  may 
not  infrequently  be  detected.  By  tapping  over  the  malar  prominence 
with  the  tip  of  the  finger,  pain  or  tenderness  is  usually  caused,  which 
is  not  experienced  on  the  sound  side.  McBride,  of  Edinburgh,  notes 
that  generally  there  is  marked  redness  of  the  gum  corresponding  to  the 
diseased  antrum  (Edinburgh  Medical  Journal,  April,  1S88). 

Diagnosis. — The  essential  points  in  the  diagnosis  are  the  pain,  fetor, 
and  discharge  from  one  naris.  The  affection  is  liable  to  be  mistaken  for 
disease  of  the  frontal  sinus  or  of  the  anterior  ethmoid  cells,  or  for 
polypus,  ozaena,  foreign  bodies,  syphilis,  caries,  or  disease  of  the 
sphenoidal  sinus.  A  useful  method  of  detecting  pus  in  this  locality 
consists  of  injecting,  through  the  normal  opening  in  the  middle  meatus, 
a  solution  of  hydrogen  peroxide,  which,  in  case  pus  is  present,  will  im- 
mediately cause  a  discharge  of  froth  through  the  opening.  Trans- 
illumination, as  suggested  by  Voltolini,  is  often,  though  not  universally, 
of  great  value  in  deciding  obscure  cases.  It  is  practised  by  means  of  a 
small  electric  lamp  placed  in  the  mouth  while  the  patient  is  in  a  dark 
room.  The  effect  of  this*  is  to  cause  a  rosy-red  suffusion  of  the  face, 
cheeks,  lips,  and  inferior  eyelid  in  health,  but  the  cheek  and  inferior 
eyelid  will  remain  dark  in  case  the  antrum  is  tilled  with  pus.  A  three 
candle  power  lamp,  five  to  eight  volts  according  to  the  strength  of  the 


EMPYEMA   OF  THE  ANTRUM.  581 

battery  used,  is  best  for  this  purpose.  It  may  be  attached  to  some  form 
of  tongue  depressor.  That  shown  in  Fig.  213,  which  is  inserted  into 
the  ordinary  galvano-cautery  handle,  I  have  found  most  convenient. 
The  patient  may  be  examined  in  a  dark  room,  or  more  easily  with  the 
aid  of  an  ordinary  photographer's  focusing-cloth  thrown  over  the  heads 
of  both  patient  and  physician.  This  method  is  of  peculiar  value  in 
detecting  cysts  of  the  antrum,  which  are  said  to  render  the  illumina- 
tion even  more  brilliant  than  in  health,  while  solid  tumors  or  pus  prevent 
the  transmission  of  light. 

Empyema,  of  the  frontal  sinus,  unattended  by  closure  of  the  duct,  is 
so  extremely  rare  that  it  may  be  excluded ;  when  the  duct  is  occluded 
the  external  signs  are  so  marked  that  the  affection  cannot  be  mistaken 
for  disease  of  the  antrum. 

We  frequently  find  suppuration  of  the  anterior  ethmoid  cells  associated 
with  empyema  of  the  antrum;  but  when  occurring  by  itself  it  is  distin- 
guished from  the  latter  by  the  position  of  the  pus  above  instead  of  below 
the  middle  turbinated  body,  and  by  the  absence  of  positive  signs  in  the 
antrum.  McDonald  recommends  as  a  means  of  diagnosis  the  introduc- 
tion into  the  antrum,  immediately  above  the  inferior  turbinated  bone, 


Fig.  213.— Ingals'  Electric  Lamp  Q/c,  size).    For  trans-illumination. 

of  a  strong,  curved,  hollow  needle,  to  which  is  attached  a  small  exhaust 
syringe  (Diseases  of  the  Nose,  1890). 

Empyema  is  distinguished  from  polypus  by  inspection  of  the  nares, 
but  it  must  be  remembered  that  before  any  operation  has  been  done, 
whenever  polypi  are  attended  with  purulent  secretion,  pus  will  usually 
be  found  in  the  antrum  at  the  same  time. 

An  extremely  fetid  breath,  which  is  appreciated  by  every  one  except 
the  patient,  is  continuously  caused  by  ozama.  The  fetor  in  empyema  of 
the  antrum  is  usually  noticed  only  by  the  patient,  and  is  apt  to  be  in- 
termittent in  its  occurrence.  Inspection  of  the  nares  in  these  cases 
will  readily  determine  the  diagnosis. 

An  offensive  discharge  from  one  nostril  may  arise  •  from  foreign 
bodies  in  the  nose,  but  they  may  be  easily  distinguished  from  disease  of 
the  antrum  by  inspection,  and  palpation  with  the  probe. 

An  offensive  odor  and  excessive  discharge  from  the  nares  may  be 
caused  by  syphilis,  but  it  nearly  always  affects  both  sides,  and  inspec- 
tion reveals  ulceration,  dead  bone,  or  other  evidence  of  disease  of  the 
cavity  itself,  instead  of  the  comparatively  healthy  appearance  found  in 
empyema  of  the  antrum.  Caries  is  also  usually  detected  in  syphilis  by 
inspection,  and  palpation  with  the  probe. 

Disease  of  the  sphenoidal  sinus  is  very  rare,  and  when  it  does  occur 


582  DISEASES  OF  THE  NASAL   CAVITIES. 

the  discharge  flows  into  the  throat,  but  not  from  the  nostrils.  It 
would  not  cause  pain  in  the  cheek  or  interference  with  the  transmission 
of  light;  therefore,  it  may  readily  be  excluded. 

Prognosis. — Acute  cases  sometimes  recover  spontaneously  within  a 
short  time,  but  the  affection  may  extend  over  many  years  unless  appro- 
priate treatment  is  adopted.  Even  under  the  most  approved  methods, 
with  free  drainage,  it  is  sometimes  impossible  to  check  the  forma- 
tion of  pus. 

Treatment. — Some  cases  have  been  cured  by  washing  out  the  an- 
trum through  the  natural  opening  with  detergent  solutions  or  with 
hydrogen  peroxide,  but  usually  free  drainage  must  be  established.  For 
this  purpose,  Hunter's  method  of  opening  the  antrum  through  the  socket 
of  one  of  the  molars  is  still  considered  best,  the  only  objection  urged 
against  it  being  the  annoyance  caused  the  patient  by  the  offensive  dis- 
cbarge into  the  mouth,  and  the  possibility  that  particles  of  food  may 
escape  into  the  antrum.  Christopher  Heath  recommends  puncture  of 
the  antrum  above  the  alveolus  (Transactions  Odontological  Society, 
November,  1889).  The  main  objection  to  this  is  the  difficulty  of  keep- 
ing   the   opening   patent.     The  antrum    may  be  opened    through    the 


Fig.  214.— Brainard\s  Bone  Drill. 

inferior  meatus  by  means  of  trephine,  drill,  knife,  or  a  long,  curved, 
strong  trocar,  as  recommended  by  Krause  (Berliner  klinischc  Wochen- 
schrift,  1889).  The  latter  position  obviates  the  objection  to  Hunter's 
method,  but  the  opening  is  less  easy  of  access,  and  is  more  difficult  to 
maintain  until  healing  has  occurred. 

My  own  preference  is  for  Hunter's  method,  a  tooth  or  a  root  being 
extracted  when  necessary,  or  an  opening  being  made  through  the  space 
4eft  by  a  tooth  which  has  been  already  lost.  Various  forms  of  trephines, 
drills  and  dental  burrs  have  been  used  for  making  the  opening,  but  in 
most  instances  too  small  an  instrument  is  employed.  I  use  Brainard's 
conical  bone-drill  (Fig.  214),  which  makes  an  opening  nearly  a  quarter 
of  an  inch  in  diameter.  Notwithstanding  statements  to  the  contrary, 
the  operation  is  extremely  painful  unless  an  anaesthetic  has  been  used. 
General  anaesthesia  may  be  induced  by  chloroform,  ether,  or  nitrous 
oxide  gas — the  effects  of  the  latter  are  usually  too  evanescent — but  in 
most  instances  the  parts  may  be  sufficiently  benumbed  by  injecting 
into  the  gum,  in  two  or  three  places  on  each  side  of  the  alveolus,  a 
solution  of  cocaine,  already  recommended  (Form.  143).  The  opening 
having  been  made,  the  antrum  should  be  washed  out  and  a  gold  or 
rubber  tube  introduced  to  maintain  its  patency.  If  this  precaution  is 
neglected,  the  opening  is  almost  sure  to  close  before  the  disease  has  been 
cured.     Any  good  dentist  can  make  a  suitable  gold  tube  which  can  be 


EMPYEMA   OF  THE  SPHENOIDAL  SINUSES.  583 

fastened  with  clamps  to  the  adjoining  teeth.  I  have  recently  used  with 
great  satisfaction  rubber  tubes  (Fig.  215)  of  six  millimetres  diameter, 
nineteen  to  thirty-five  millimetres  length,  and  four  millimetres  calibre, 
with  flanges  at  each  end.  With  a  wire,  the  end  of  which  has  been  bent 
to  a  right  angle,  the  distance  through  the  alveolus  may  be  measured 
and  a  tube  of  proper  length  selected.  The  flange  at  the  upper  end  of 
the  tube  is  thinned,  by  cutting  away  its  upper  surface,  until  it  may 
be  squeezed  into  a  gelatin  capsule  of  proper  size.  This  is  then  oiled  and 
readily  passed  through  the  opening  into  the  antrum.     A  probe  is  then 


Fig.  215. — In-gals'  Drainage  Tube  for  Antrum.    Full  diameter;  three  different  lengths. 

passed  through  the  tube,  the  gelatin  capsule  forced  off,  the  flange  opens 
out,  and  the  tube  is  thoroughly  secure.  These  tubes  are  inexpensive 
and  very  much  more  comfortable  to  the  patient  than  gold.  The  sub- 
sequent treatment  consists  of  keeping  the  cavity  clean,  and  stimulating 
the  healing  process  by  injections  of  iodine,  zinc,  copper,  or  hydrogen 
peroxide  in  watery  solution;  or  by  insufflations  of  boric  acid,  iodol, 
iodoform,  or  aristol;  or  by  solutions,  in  liquid  albolene,  of  carbolic  acid, 
oil  of  cloves,  oil  of  cinnamon,  or  terebene.  If  septa  prevent  thorough 
cleansing  of  the  cavity,  it  may  be  necessary  to  enlarge  the  opening  and 
break  them  down.  The  patient  should  always  stop  the  opening  with  a 
pledget  of  cotton  while  eating. 

EMPYEMA  OF    THE   SPHENOIDAL  SINUSES. 

Empyema  of  the  sphenoidal  sinuses  is  so  extremely  rare  that  no  defi- 
nite rules  for  diagnosis  or  treatment  can  be  formulated.  These  sinuses, 
which  occupy  a  position  at  the  upper  back  part  of  the  nasal  cavity, 
just  at  its  opening  into  the  naso-pharynx,  vary  in  number,  size,  and 
form  in  different  individuals  (Fig.  216). 

Symptomatology. — Purulent  inflammation  of  these  cavities  gives 
rise  to  a  persistent  discharge  of  pus  into  the  nares  and  naso-pharynx,  and 
not  infrequently  causes  severe  headache,  with  more  or  less  disturbance 
of  the  senses  of  smell  and  sight. 

The  anterior  wall  of  the  sphenoidal  sinus,  as  shown  in  Fig.  216,  is 
thin,  and  in  cases  of  long-continued  empyema  a  spontaneous  opening 
through  it  might  be  effected.  The  finding  of  pus  uniformly  in  this 
position,  or  trickling  from  it  down  the  sides  into  the  posterior  nares, 
may  suggest  the  true  nature  of  the  disease. 

Treatment. — Other  affections  being  excluded,  and  the  diagnosis 
established,  the  anterior  wall  of  the  sinus  should  be  carefully  perforated, 
and  the  cavity  drained  and  treated  ou  the  same  principles  as  empyema 


584 


DISEASES   OF  THE  NASAL   CAVITIES. 


of  the  antrum.     Opening  has  also  been  successfully  effected  through  the 
inner  wall  of  the  orbit  in  extreme  cases. 

INFLAMMATION   OF  THE  FRONTAL  SINUS. 

Inflammation  of  the  frontal  sinus  is  a  comparatively  frequent  affec- 
tion, but  owing  to  the  dependent  position  of  the  duct  in  most  cases  the 
products  of  inflammation  readily  escape  and  spontaneous  recovery  speed- 
ily follows.  Sometimes,  however,  swelling  obstructs  the  duct,  and  the 
secretions  may  be  pent  up.     Such  cases  I  have  seen  readily  relieved  by 


ff^^^Sm^^^^ 


Fig.  216.— Cross  Section  of  Head.  From  photograph  of  frozen  section  prepared  by  C.  H. 
Stolen  (4-5  natural  size),  a.  Middle  turbinated  body;  b.  inferior  turbinated  body;  c,  superior 
turbinated  body;  d,  sphenoid  cells;  e,  frontal  sinus;  /,  Eustachian  orifice;  g,  naso-pharynx  as 
closed  in  deglutition. 


the  local  use  of  cocaine,  which  reduced  the  swelling  sufficiently  to  allow 
free  discharge,  and,  this  condition  being  maintained  for  two  or  three 
weeks,  recovery  ensued.  In  some  instances,  permanent  obstruction 
of  the  duct  occurs,  and  then  empyema  of  the  frontal  sinus  follows. 
^\  hen  this  results,  the  pent-up  secretions  eventually  cause  a  tumor 
at  the  upper  inner  angle  of  the  orbit,  disfiguring  the  patient,  and 
displacing  the  globe  of  the  eye. 

The  occurrence  of  suppuration  will  be  indicated  by  rigors,  exces- 
sive headaches,  swelling,  redness,  and  some  local  oedema  and  throb- 
bing pain.     Violent  pain  in  the  course  of  the  supra-orbital  and  nasal 


CHRONIC  SUPPURATIVE  ETH2I0IDITI8.  585 

nerves  is  a  common  symptom.  In  suppuration  caused  by  simple  catar- 
rhal inflammation,  a  small  opening  made  with  a  drill  from  the  nasal 
cavity,  is  usually  sufficient  to  allow  the  confined  secretions  to  escape; 
but  when  it  results  from  syphilis,  energetic  measures  are  demanded, 
otherwise  fatal  involvement  of  the  brain  is  likely  to  ensue.  Then 
the  frontal  bone  should  be  laid  bare,  and  the  cavity  opened  with  a  tre- 
phine in  its  most  dependent  part.  Afterward  provision  should  be  made 
for  free  drainage  into  the  nasal  cavity,  a  drainage  tube  introduced,  and 
the  external  wound  allowed  to  heal.  Finally,  as  recovery  takes  place, 
the  drainage  tube  is  removed  through  the  nose.  Other  diseases  of  the 
frontal  sinus  come  more  properly  within  the  domain  of  general  surgery. 

CHRONIC  SUPPURATIVE  ETHMOIDITIS. 

A  chronic  suppurative  inflammation  of  the  ethmoid  bone  and  mem- 
brane lining  its  cells  is  characterized  by  a  persistent,  somewhat  offen- 
sive discharge,  and  obstinate  neuralgic  pains  in  the  temples  and  forehead. 

Etiology. — The  causes  are  unknown.  In  two  cases  which  have 
come  under  my  observation,  I  am  satisfied  that  the  disease  was  the  direct 
result  of  inflammation  of  the  antrum,  and  not  the  cause  of  the  latter,  as 
it  is  believed  often  to  be  by  McDonald  (Diseases  of  the  Nose,  1890). 
The  suppuration  results  from  abscess  of  the  antrum  in  consequence  of 
the  occlusion  of  the  opening  from  the  latter  into  the  nasal  cavity,  so 
that  it  becomes  filled  with  pus  which  crowds  upward  and  finally  flows 
from  the  openings  which  are  frequently  present  between  the  antrum  and 
the  ethmoid  cells;  by  pressure  this  pus  causes  necrosis  and  perforation 
of  the  thin  bones  which  separate  the  two  cavities.  The  relation  of  parts 
will  be  readily  understood  by  reference  to  Fig.  212. 

Symptomatology. — Patients  frequently  suffer  from  neuralgic  pains 
in  the  temple  or  over  the  orbit,  which  are  more  or  less  intermittent, 
and  sometimes  paroxysmal.  Indeed,  the  symptoms  closely  resemble 
some  of  those  attributed  to  empyema  of  the  antrum;  but  there 
may  be  reasonable  doubt  whether  these  symptoms  would  occur  in  the 
latter  affection  were  it  not  for  coexisting  disease  of  the  ethmoid  cells. 
There  is  usually  purulent  or  muco-purulent  discharge  from  the  nose, 
which  is  often  fetid,  but  not  so  offensive  as  in  ozasna.  This  flux  may 
be  scanty  or  very  profuse,  is  generally  continuous,  and  usually  comes 
from  one  side  only.  Upon  inspection  it  may  be  seen  filling  the  middle 
meatus  and  running  over  the  middle  turbinated  body.  Often  inflam- 
matory thickening  of  the  external  wall  of  the  middle  meatus  is  seen, 
which  sometimes  communicates  through  the  probe  a  sensation  of  bony 
hardness,  but  usually  it  appears  and -feels  more  like  a  polypoid  for- 
mation or  fungous  granulation. 

Diagnosis. — The  affection  is  to  be  distinguished  from  mucous  polypi, 
atrophic  rhinitis  with  ozama,  from  suppuration  of  the  antrum,  and  from 


5b»; 


DISEASES   OF  THE  NASAL  CAVITIES. 


empyema  of  the  sphenoidal  and  frontal  sinuses.  It  may  ordinarily  he 
distinguished  from  mucous  polypi  by  the  presence  of  pus;  this  must 
he  wiped  away,  and  carious  hone  which  often  exists,  or  fungous  granu- 
lations are  to  he  carefully  sought  with  the  probe.  Not  infrequenly 
small  polypi  are  associated  with  this  affection. 

Suppurative  ethmoiditis  must  be  distinguished  from  suppuration  of 
the  antrum  by  careful  inquiry  into  the  history  and  symptoms  and  by 
persistence  of  the  discharge  after  the  latter  cavity  is  known  to  be  healed. 
TVe  readily  distinguish  atrophic  rhinitis  by  the  abnormal  size  of  the  nasal 
cavities,  the  peculiar  stench,  and  collections  of  decaying  crusts  of  mu co- 
pus.  From  empyema  of  the  sphenoidal  and  frontal  sinuses  this  affection 
is  distinguished  according  to  Max  Schaeffer  {Deutsche  Medinische  Wo- 
chenschrift,  Leipzig,  No.  41,  1890),  largely  by  the  position  of  the  pus, 
which  in  disease  of  the  frontal  sinus  covers  the  more  or  less  swollen 
mucous  membrane  of  the  septum  in  the  superior  meatus,  and  in  disease 
of  the  sphenoid  cells  passes  down  the  pharynx,  while  in  ethmoiditis  it 
spreads  out  in  the  middle  meatus. 

Prognosis  and  Treatment. — It  is  probable  that  some  of  the  cases 
recover  spontaneously,  but  most  of  them  continue  for  many  months,  and 
even  years,  in  spite  of  the  best-directed  treatment.  The  indications  are 
to  remove  any  obstruction  which  prevents  free  exit  of  pus;  to  keep  the 
parts  cleansed,  and  as  nearly  aseptic  as  possible;  and  by  judicious  stimu- 


FlG.  217.— Holbrook  Curtis'  Wash  Bottle  C%  size).    Used  for  the  ethmoid  cells. 

lation  to  encourage  healing.  If  disease  of  the  antrum  exists,  it  must 
be  remedied  before  we  can  hope  to  cure  the  disease  of  the  ethmoid  cells. 
Polypoid  growths  or  fungous  granulations  may  he  best  removed  by  snare 
or  sharp  spoon,  or  small  masses  may  be  touched  with  the  galvano-cautery 
or  with  monochloracetic  acid.  Dead  bone  must  be  carefully  scraped 
away,  and  with  the  drill,  trephine,  or  forceps  the  partitions  of  the  eth- 
moid cells  may  be  broken  down  to  give  free  exit  to  the  pus;  hut  care 
must  be  taken  not  to  excite  undue  inflammation,  which  might  extend  to 
the  brain.  I  have  found  the  most  satisfactory  results  from  injecting 
into  the  ethmoid  cells,  with  a  long,  slender  silver  canula  attached  to  a 
hypodermic  syringe,  about  fifty  per  cent  solutions  of  the  hydrogen 
peroxide,  and  subsequently  oily  solutions  containing  oil  of  gaultheria 


LUPUS  OF  THE  If  ARES.  587 

TTi  I,  oil  of  caryophyllum  Til  v.,  terebene  TT[  x.,  ad  3  i.  of  liquid  albolene, 
the  strength  being  slightly  increased  or  diminished  according  to  its 
effect.  It  should  not  cause  pain  for  more  than  half  an  hour  after- 
ward. At  the  same  time  the  nasal  cavity  should  be  washed  two  or  three 
times  daily,  by  means  of  the  nasal  syringe  or  Curtis'  wash-bottle  (Fig. 
217),  with  a  detergent  solution,  and  a  similar  oily  preparation,  or  one 
somewhat  weaker  may  be  used  as  a  spray  by  the  patient  morning  and 
evening.  A  powder  containing  five  per  cent  of  aristol,  two  per  cent  of 
cocaine,  twenty  per  cent  of  boric  acid,  forty  per  cent  of  iodol,  with  sugar 
of  milk  for  an  excipient,  may  be  advantageously  used  by  the  patient 
once  or  twice  daily  as  an  insufflation. 

LUPUS  OF  THE  NARES. 

Lupus  of  the  nares  is  a  chronic  affection  of  the  mucous  membrane 
usually  secondary  to  lupus  of  the  external  surface  of  the  nose,  and 
characterized  by  the  formation  of  small,  irritable  nodules  which  sub- 
sequently are  the  seat  of  iudolent  ulceration,  followed  frequently  by 
a  process  of  slow  repair  and  cicatrization.  It  generally  occurs  in  young 
persons  of  strumous  habit,  and  is  most  liable  to  affect  girls. 

Anatomical  and  Pathological  Characteristics. — Two  varie- 
ties of  the  affection  are  recognized;  one  known  as  lupus  non-exedens,  in 
which  atrophy  of  the  affected  tissues,  including  bone  and  cartilage, 
occurs  without  ulceration ;  the  other  as  lupus  exedens,  which  usually 
begins  on  the  cartilaginous  septum  in  the  form  of  small,  red,  irritable 
nodules;  these  gradually  coalesce,  forming  raised, uneven  patches,  which 
ere  long  become  the  seat  of  deep  ulceration.  This  process  extends 
slowly,  destroying  the  soft  tissues,  cartilages,  and  even  the  bones,  though 
repair  is  often  inaugurated  before  the  latter  perish.  The  ulcers  are 
covered  with  crusts  under  which  the  destructive  process  is  going  on  in 
some  places,  while  healing  may  be  taking  place  in  others. 

Etiology. — Pathologists  now  generally  recognize  lupus  as  a  tuber- 
cular disease,  but  the  clinical  history  of  the  affection  still  leaves  much 
doubt  as  to  its  true  nature,  and  a  large  part  of  the  profession  is  still 
unwilling  to  accept  any  dictum  concerning  it. 

Symptomatology. — The  disease  occurs  in  young  subjects,  progresses 
slowly,  causing  the  physical  appearance  already  described,  and  it  is  at- 
tended by  a  discharge  more  or  less  profuse  and  offensive.  The  ulcers 
are  not  usually  painful.  As  a  rule,  the  disease  first  attacks  the  skin 
upon  the  cheek  or  nose,  but  it  occasionally  commences  in  the  mucous 
membrane. 

Diagnosis. — Lupus  is  liable  to  be  mistaken  for  syphilitic  affections 
of  the  nose,  epithelioma,  and  true  tubercular  disease.  The  essential 
points  in  the  diagnosis  are  the  history,  the  development  of  red,  irritable 
nodules,  the  progressive  ulceration,  and  the  slow  process  of  repair. 


588  DISEASES   OF  THE  NASAL   CAVITIES. 

There  is  usually  a  specific  history  in  syphilis,  which  may  be  obtained 
by  the  adroit  physician  ;  thickening  of  the  mucous  membrane  in  patches 
or  extensive  swelling  of  the  turbinated  bodies  comes  on  rapidly  and  is 
quite  unlike  the  slowly  developing,  small,  red  tubercles  seen  in  lupus. 
Syphilitic  ulceration,  though  rapid,  may  usually  be  soon  checked  by  ap- 
propriate local  and  internal  remedies,  which  make  no  impression  upon 
lupus. 

We  cannot  always  distinguish  epithelioma  from  lupus  in  the  be- 
ginning, but  after  a  short  time  the  characteristic  features  of  the  two 
diseases  render  the  diagnosis  easy. 

The  small  red  nodules  found  in  lupus  do  not  precede  true  tuber- 
cular ulceration,  in  which  the  ulcers  are  of  a  lighter  color  and  present 
few  if  any  of  the  bright  red  granulations  usually  seen  in  lupus,  and 
show  no  tendency  to  repair.  The  presence  of  pulmonary  tuberculosis 
would  lie  a  valuable  point  in  the  diagnosis. 

Prognosis. — The  disease  continues  for  several  years,  but  can  some- 
times be  checked  by  appropriate  treatment,  though  even  when  the 
ulceration  has  healed  there  is  great  tendency  to  recurrence,  especially 
if  the  cicatrices  remain  red  and  indurated.  With  advancing  age  there 
is  sometimes  spontaneous  recovery.  In  some  instances  it  extends  to 
the  pharynx  and  larynx;  in  these,  recovery  is  not  likely  to  take  place.   4 

Treatment. — Arsenious  acid  and  other  tonics,  with  cod-liver  oil, 
sometimes  prove  beneficial.  The  local  treatment  consists  in  removing 
or  destroying  the  diseased  tissues  by  the  knife,  curette,  caustic,  or  the 
galvano-cautery.  The  treatment  generally  recommended  consists  of 
scraping  the  ulcers  thoroughly  with  the  curette,  and  then  applying 
lactic  acid,  which  should  be  repeatedly  used  until  the  process  of  repair 
is  thoroughly  established;  other  powerful  caustics  such  as  nitric  acid, 
caustic  potash,  and  zinc  chloride  have  been  recommended,  but  they 
are  more  severe  and  seem  no  more  effective  than  lactic  acid.  The 
galvano-cautery  has  also  been  efficiently  used  for  the  same  purpose. 
Koch's  tuberculin  has  a  wonderful  effect  on  the  disease,  and  has  proven 
curative  in  some  cases.  Complete  removal  by  the  knife  is  sometimes 
practised. 

RHIXOSCLEROMA. 

Rhinoscleroma  is  a  rare  affection,  most  cases  of  which  have  been  ob- 
served in  Austria,  Hungary,  and  Italy,  but  a  few  have  been  seen  in 
Germany.  As  described  it  is  characterized  by  the  formation  about  the 
nostrils  or  upper  lip  of  smooth,  flat,  slightly  raised,  and  extremely  hard 
patches.  The  integument  over  these  is  either  natural  or  of  a  reddish  hue, 
and  the  spots  are  tender  on  pressure,  but  not  otherwise  painful.  Xo  con- 
stitutional symptoms  are  developed.  The  disease  may  appear  in  two  or 
more  places  simultaneously;  it  progresses  slowly,  and  may  involve  the 
alae  of  the  nose  and   septum,  and  may  pass  backward  to  the   throat, 


GLANDERS.  58  9 

larynx,  and  even  the  trachea,  causing  extensive  swelling  of  the  mucous 
membrane  and  symptoms  due  to  mechanical  interference  with  the  func- 
tions of  the  parts. 

Etiology. — Ehinoscleroma  is  probably  due  to  local  infection,  but 
the  specific  cause  has  not  yet  been  identified,  though  micro-organisms 
are  always  to  be  found  in  the  cells  and  lymphatic  spaces  of  the  affected 
part,  and  some  of  these  have  been  specially  studied. 

Diagnosis. — Ehinoscleroma  is  to  be  distinguished  from  syphilis, 
epithelioma,  and  keloid.  It  is  differentiated  from  syphilis  by  its  chronic 
course,  the  absence  of  softening  and  ulceration,  and  the  fruitlessness  of 
specific  medication.  Epithelioma  is  softer,  it  soon  ulcerates  and  bleeds, 
which  does  not  occur  in  the  affection  under  consideration  and  it  is 
much  shorter  in  duration.  Ehinoscleroma  must  be  distinguished  from 
keloid  by  the  location  and  progress  of  the  case.  Keloid  usually  occurs 
on  the  front  of  the  chest  as  an  irregular,  corrugated,  cicatrix-like  ex- 
crescence, of  slow  growth. 

Prognosis. — There  is  no  tendency  to  spontaneous  recovery,  and  if 
extirpated  or  destroyed  it  is  sure  to  recur,  but  it  does  not  shorten  life. 

Treatment. — Treatment  is  of  no  avail  except  as  a  palliative  meas- 
ure; obstructing  masses  should  be  removed  from  the  air  passages,  and. 
in  case  the  larynx  becomes  involved,  tracheotomy  should  be  performed 
to  prevent  suffocation.     Injection  of  Koch's  tuberculin  produces  no  re- 
action in  these  cases. 

GLANDERS. 

Glanders  is  a  contagious  disease  derived  directly  by  inoculation 
usually  from  a  horse  suffering  from  the  affection.  It  is  characterized  by 
the  formation  of  nodules,  which  soon  become  pustular  and  ulcerated,  with 
symptoms  of  septicaemia  and  thick,  muco-purulent,  or  sanious,  offensive 
discharge.  The  affection  is  rare  and  is  hardly  observed  except  among 
veterinary  surgeons,  grooms,  coachmen,  and  others  whose  occupation 
brings  them  in  contact  with  horses.  The  disease  may  extend  to  the 
skin  and  various  parts  of  the  body,  causing  inflammation  of  the  lym- 
phatics, and  it  is  then  termed  farcy.  It  may  be  either  acute  or  chronic; 
the  chronic  form  frequently  precedes  the  acute. 

Anatomical  and  Pathological  Characteristics. — There  is  usu- 
ally but  little  swelling  and  redness  of  the  mucous  membrane,  which  is 
covered  by  scabs,  beneath  which  ulcers  will  be  found  in  several  places; 
it  extends  in  less  degree  to  the  mouth,  throat,  and  larynx. 

Etiology. — Glanders  in  the  human  subject  is  always  caused  by  direct 
inoculation  from  a  horse  suffering  from  the  disease,  and  is  due  to  the 
bacillus  malei. 

Symptomatology. — The  acute  form  is  marked  at  its  outset  by  chills, 
high  fever,  and  erysipelatous  rash  on  the  nose  and  face,  soon  followed  by 
vesicles  which  burst  and  discharge  a  thin,  serous  fluid.     These  pustules 


590  DISEASES  OF  THE  NASAL  CAVITIES. 

appear  on  the  face  associated  with  blebs.  The  secretion  soon  dries 
and  forms  a  crust,  under  which  a  deep  and  rapidly  spreading  nicer  is 
found.  Obstruction  in  the  nose  and  throat  is  caused  by  the  pustules. 
The  chronic  affection  is  characterized  by  similar  symptoms,  coming  on 
more  slowly,  but  it  is  likely  to  be  merged  suddenly  into  the  acute  form. 
When  the  disease  becomes  fairly  developed,  the  muscles  and  tendons 
are  often  tender  and  the  seat  of  rheumatic  pain.  The  voice  be- 
comes husky  or  even  lost,  and  some  dyspnoea  may  develop ;  frequently 
there  is  slight  cough.  The  discharge  from  the  nose  and  throat  is  always 
extremely  offensive,  and  usually  profuse  and  thin  at  first,  but  later 
thick  and  glutinous,  and  sometimes  streaked  with  blood.  Nausea, 
diarrhoea,  and  abdominal  pains  are  sometimes  experienced.  As  the  dis- 
ease progresses,  the  patient  passes  into  a  typhoid  condition,  which,  in 
the  acute  form  soon  terminates  in  coma  and  death.  In  the  chronic 
form  the  patient  may  remain  ill  for  several  years,  and  he  seldom  fully 
regains  his  health. 

Diagnosis. — Glanders  is  liable  to  be  mistaken  for  rheumatism,  py- 
aemia, typhoid  fever,  syphilis,  and  scrofulous  eruptions.  The  essential 
points  in  the  diagnosis  are :  the  history  of  infection,  the  marked  consti- 
tutional symptoms,  nasal  obstruction  and  offensive  discharge,  pains  in  the 
limbs,  and  abscesses  in  various  parts  of  the  body.  It  will  be  distinguished 
from  rheumatism  by  the  history,  the  presence  of  pustules  and  ulcera- 
tion, and  the  occurrence  of  pain  in  the  muscles  and  tendons,  instead  of 
in  the  articulations.  It  will  be  distinguished  from  pyaemia  by  less 
pronounced  rigors,  and  by  the  pustules,  ulceration,  and  offensive  nasal 
discharge.  It  will  be  differentiated  from  typhoid  fever  by  the  history, 
the  pustules,  ulceration,  and  discharge.  There  should  be  no  difficulty 
in  distinguishing  glanders  from  syphilis,  if  the  history,  marked  consti- 
tutional symptoms,  and  failure  of  specific  medicines  to  give  relief  are 
considered.  It  is  readily  distinguished  from  scrofulous  eruptions  by 
the  marked  constitutional  symptoms. 

Prognosis. — The  chronic  disease  usually  runs  from  four  to  eight 
months  or  even  longer.  Bollinger  (Ziemssen's  Cyclopaedia  of  Medicine) 
mentions  a  case  in  which  the  symptoms  lasted  for  eleven  years. 

The  acute  affection  usually  lasts  for  about  three  weeks  when  coming 
on  independently;  but  when  following  the  chronic  disease,  it  generally 
terminates  fatally  within  a  week.  The  acute  disease  is  almost  always 
fatal,  probably  always  if  the  nose  is. attacked.  The  symptoms  preceding 
a  fatal  termination  are  protracted  fever,  night  sweats,  diarrhoea,  delirium, 
and  great  exhaustion. 

Treatment. — No  form  of  treatment  seems  to  be  of  any  avail,  but 
the  case  should  be  managed  on  general  principles,  and  an  attempt  made 
to  relieve  suffering  and  sustain  the  vital  powers. 


PERVERTED  SENSE  OF  SMELL.  591 

NASAL  AFFECTIONS   IN  ACUTE  DISEASES. 

Acute  coryza  is  one  of  the  earliest  symptoms  of  measles  and  it  is  oc- 
casionally followed  by  severe  inflammation,  with  epistaxis  and  muco- 
purulent secretions.  Atrophic  rhinitis  and  ulceration  of  the  septum 
sometimes  result. 

Slight  or  severe  acute  rhinitis,  with  profuse  serous  or  muco-purulent 
discharge  and  sometimes  epistaxis,  may  attend  scarlet  fever. 

An  eruption  in  the  nares,  with  obstruction  of  the  passages,  and  sub- 
sequently epistaxis,  is  sometimes  caused  by  small-pox,  and  cases  are  not 
very  uncommon  where  the  nostrils  have  become  occluded  by  healing  of 
the  ulcerated  surfaces. 

Very  distressing  catarrhal  symptoms,  due  to  collection  of  secretions 
and  formation  of  large  crusts,  sometimes  attend  typhoid  fever.  Under 
the  crusts,  ulceration  may  possibly  take  place,  and  sometimes  the  sep- 
tum is  partially  destroyed. 

Severe  rhinitis  sometimes  attends  rlieumatism,  but  more  frequently 
will  be  observed  rheumatic  or  neuralgic  pains,  associated  with  but  little 
if  any  evidence  of  inflammation.  In  all  of  these  cases  the  diagnosis  is 
comparatively  easy,  and  the  local  treatment  is  that  suitable  for  acute 
catarrhal  rhinitis. 

PERVERTED   SENSE  OF  SMELL. 

Parosmia. 

Parosmia  indicates  a  perversion  of  the  sense  of  smell  by  which  the 
patient  experiences  sensations  of  odors,  usually  disagreeable,  which  are 
not  really  present.  It  is  said  to  be  comparatively  common  in  epileptics' 
and  among  the  insane,  but  is  also  observed  in  those  who  are  otherwise 
perfectly  healthy.  The  condition  is  analogous  to  neuralgia  of  a  nerve 
of  common  sensation.  In  some  it  is  constantly  present,  in  others  in- 
termittent. In  some  patients  the  sensation  occurs  without  an  exciting 
cause,  whereas  in  others  agreeable  odors  smell  offensive. 

Diagnosis. — The  diagnosis  is  made  from  the  subjective  features  of 
the  disease. 

Treatment. — No  rules  for  treatment  can  be  formulated. 

Anosmia. 

Anosmia  or  loss  of  the  sense  of  smell  is  dependent  upon  obstructions 
in  the  nares  or  disease  of  the  olfactory  nerves  or  lobes,  or  of  their  cere- 
bral centres. 

Etiology. — Anosmia  is  caused  by  obstruction  of  the  nares  from  an 
acute  cold,  polypi,  hypertrophy  of  the  mucous  membrane,  or  presence 


DISEASES   OF  THE  NASAL   CAVITIES. 

of  foreign  bodies;  also  by  disease  of  the  olfactory  nerves,  either  distal, 
or  along  the  trunk,  or  at  the  centres.  The  most  frequent  cause  is 
obstruction  from  mucous  polypi,  or  swelling  of  the  middle  turbinated 
body,  or  of  the  mucous  membrane  covering  the  septum  directly  opposite. 
In  these  cases  it  is  usually  intermittent.  It  not  infrequently  results 
from  injury  to  the  head,  as  from  blows  or  falls,  and  cases  are  on  record 
in  which  it  has  been  caused  by  prolonged  exposure  of  the  olfactory  nerve 
to  some  pungent  or  extremely  disagreeable  odor.  It  has  been  caused  by 
inhalation  of  irritating  vapors,  snuff-taking  and  local  use  of  solutions 
of  alum,  or  other  nasal  washes.  It  sometimes  follows  prolonged  rhinitis 
especially  of  the  dry  variety,  frontal  neuralgia,  or  long-continued  paral- 
ysis of  the  fifth  or  seventh  nerve,  and  it  is  occasionally  congenital. 

Symptomatology. — In  addition  to  the  loss  of  smell,  the  patient  is 
usually  deprived  of  the  sense  of  taste  for  all  substances  with  a  dis- 
tinct flavor,  but  bitter,  sweet,  sour,  salt,  and  acids  are  usually  recognized. 
The  loss  of  the  sense  of  smell  may  be  unilateral  or  bilateral,  and  is 
often  intermittent,  returning  for  a  few  minutes  or  even  days,  after  ex- 
ertion or  without  evident  cause;  but  disappearing  again  without  the 
slightest  known  provocation. 

Diagnosis. — The  diagnosis  is  made  from  the  subjective  symptoms 
and  the  exclusion  by  inspection  of  conditions  causing  obstruction  of  the 
nares. 

Prognosis. — When  due  to  mechanical  obstruction,  most  cases  are 
relieved  when  the  obstruction  has  been  removed.  Cases  dependent 
upon  catarrhal  inflammation  of  the  Schneiderian  membrane  usually  re- 
cover unless  they  have  already  existed  for  two  or  three  years,  in  which 
case  a  favorable  termination  cannot  be  expected.  When  due  to  cerebral 
disease,  the  sense  of  smell  is  seldom  restored. 

Treatment. — The  condition  causing  the  affection  should  be  sought 
and,  if  possible,  removed  When  this  cannot  be  found,  Mackenzie  rec- 
ommends the  insufflation  of  a  powder  containing  one  twenty-fourth  of 
a  grain  of  strychnine  with  two  grains  of  starch  twice  a  da}',  and  if  it 
does  not  succeed  he  increases  the  strychnine  to  one-sixteenth  or  even 
one-twelfth  of  a  grain  (Diseases  of  the  Throat  and  Xose). 


CHAPTER  XXXV. 

DISEASES   OF   THE   NASAL   CAVITIES.— Continued. 

CONGENITAL  DEFORMITY  OF  THE  NOSE. 

The  principal  nasal  deformities  which  have  been  observed  are :  ab- 
sence of  the  septum,  double  septum,  narrowness  of  one  naris  as  compared 
with  the  other,  and  occlusion  of  the  posterior  nares  by  membranous  or 
bony  tissues.  Cases  have  also  been  recorded  of  complete  absence  of  the 
nose,  and  of  double  nose.  Closure  of  the  posterior  nares  seriously  inter- 
feres with  respiration,  especially  in  infants,  and  in  them  may  be  a  seri- 
ous menace  to  life. 

Treatment. — Various  plastic  operations  have  been  performed  to 
correct  these  deformities.  Congenital  closure  of  the  posterior  nares, 
which  principally  concerns  us,  demands  prompt  attention,  for  infants 
will  not  thrive  unless  they  can  breathe  through  the  nose.  A  passage 
must  be  forced  through  the  obstruction  by  a  strong  probe,  blunt  for- 
ceps, or  other  instrument,  and  the  opening  thus  made  must  be  dilated 
and  kept  open  until  healing  occurs. 

FRACTURES  OF  THE  NOSE. 

Fractures  of  the  nose  are  usually  caused  by  falls  upon  the  sharp 
edge  of  a  step  or  the  corner  of  a  table,  blows  from  the  fist,  a  baseball 
bat,  or  flying  missile,  or  the  kick  of  a  horse. 

Symptomatology. — The  injuries  vary  from  a  slight  fracture  to  com- 
plete crushing  of  the  nose  with  great  displacement  and  more  or  less  in- 
jury to  the  surface.  There  is  usually  much  swelling  and  ecchymosis  of 
the  parts  and  frequently  subcutaneous  emphysema.  Profuse  bleeding 
is  likely  to  occur  at  the  time  of  the  accident,  and  to  recur  from  time  to 
time  on  sneezing  or  blowing  of  the  nose.  The  sense  of  smell  is  often 
lost  at  first,  and  sometimes  it  is  permanently  destroyed. 

Diagnosis. — In  order  to  make  an  accurate  examination,  it  is  some- 
times only  necessary  to  inspect  the  part  with  the  aid  of  the  speculum 
and  rhinoscope;  but  if  much  contusion  has  occurred,  complete  anaes- 
thesia should  be  induced,  to  allow  of  careful  manipulation,  but  even  then 
crepitus  is  not  often  detected. 

Prognosis. — Great  deformity  may  result  if  the  injury  be  not  prop- 
erly attended  to  at  the  time,  and  it  must  not  be  forgotten  that  a  blow 
-8 


o'J4  DISEASES  OF  THE  NASAL   CAVITIES. 

may  have  also  caused  fracture  of  the  base  of  the  skull  and  serious  injury 
to  the  brain. 

Treatment. — With  the  patient  under  an  anaesthetic,  the  fragments 
should  be  replaced,  as  nearly  as  possible  in  their  normal  position,  by  the 
finger  and  forceps;  and  if  there  has  been  much  displacement,  the  part 
should  be  retained  by  plugging  the  nares  lightly  with  antiseptic  wool  or 
by  the  introduction  of  plugs  or  tubes  of  gutta-percha  or  other  sub- 
stances, or  by  a  spring,  as  practised  by  Roe  (New  York  Medical  Record, 
July,  1891).  At  the  same  time  a  plaster  of  Paris  dressing  may  be  ap- 
plied with  benefit  externally.  Sometimes  it  will  be  necessary  first  to 
reduce  the  swelling  by  cold  applications,  and  wait  from  twenty-four  to 
forty-eight  hours  before  an  attempt  is  made  to  replace  the  fragments; 
but  it  must  be  remembered  that  healing  in  this  location  takes  place 
very  rapidly,  and  it  is  desirable,  therefore,  to  correct  the  deformity  be- 
fore union  has  occurred. 

DISLOCATION   OF  THE  NASAL  BONES. 

Dislocation  of  the  nasal  bones  is  a  rare  accident,  which  in  the  few 
reported  cases  has  resulted  from  a  blow  on  the  side  of  the  nose  by  which 
the  bones  at  the  upper  third  of  the  organ  have  been  laterally  displaced. 
Reduction  is  accomplished  by  means  of  combined  internal  and  external 
manipulation  while  the  patient  is  fully  anaesthetized. 

DEFLECTION   OF  THE  NASAL  SEPTUM. 

Uncomplicated  deflection  of  the  septum  does  not  often  exist,  but, 
associated  with  thickening  of  the  cartilage  and  bone  or  enchondroma 
and  exostosis,  it  is  one  of  the  most  common  deformities  of  the  nose.  In- 
deed, Mackenzie  found  a  deflection  of  from  half  a  millimetre  to  nine 
millimetres  in  over  seventy-six  per  cent  of  2,152  crania  examined  in 
the  museum  of  the  Royal  College  of  Surgeons  (Diseases  of  the  Throat 
and  Nose).  Delavan  has  found  among  European  races  well  marked 
deflection  in  fifty  per  cent  of  several  thousand  crania  examined  (Trans- 
actions of  the  American  Laryngological  Association,  1887). 

Anatomical  and  Pathological  Characteristics. — The  cartilagi- 
nous or  the  bony  septum,  or  both  portions,  are  simply  bent  to  one  side, 
the  cartilaginous  portion  usually  being  most  involved.  The  deformity 
cause  enlargement  of  one  nasal  chamber,  at  the  expense  of  its  fellow. 
Simple  bending  of  the  septum  is  uncommon,  for  in  most  instances  of 
deflection  there  is  also  thickening,  especially  at  the  lower  part  of  the 
convex  surface. 

Etiology. — The  causes  of  the  affection  are  obscure.  It  was  at  one 
time  thought  to  be  often  congenital,  but  Znckerkandl,  as  reported  by 
Mackenzie  and  Delavan,  states  that  it  is  never  found  before  the  seventh 


DEFLECTION  OF  THE  NASAL  SEPTUM.  595 

year;  this,  however,  is  a  mistake,  for  I  have  operated  upon  several  cases 
in  children  under  four  years  of  age,  and  I  observed  it  in  a  child  less 
than  eighteen  months  old.  Delavan  believes  that  it  is  generally  due  to 
injury,  especially  when  situated  anteriorly,  and  that  otherwise  it  is  due 
to  hypernutrition,  particularly  when  located  posteriorly  (op.  cit.).  Chas- 
saignac  attributes  it  to  hypernutrition  (Bulletin  de  la  Societe  de  clii- 
rurgie,  1851  to  1852,  Tome  II).  My  own  observation  is  in  accord  with 
that  of  Delavan,  excepting  that  I  have  found  comparatively  few  cases 
that  could  be  clearly  traced  to  an  injury;  and  the  evidence  in  support 
of  some  of  the  older  views,  as  suggested  by  Mackenzie,  is,  to  say  the 
least,  insufficient.  It  is  probable  that  not  infrequently  trauma  is  the 
starting-point,  but  undoubtedly  chronic  catarrhal  congestion,  by  deter- 
mining an  increased  flow  of  blood  to  the  part,  gives  rise  to  hyperplasia. 

Symptomatology. — When  the  deflection  is  great,  the  most  promi- 
nent symptom  is  twisting  of  the  nose  to  one  side,  usually  opposite  the 
convexity  of  the  septum.  This  deformity  is  sometimes  very  marked 
from  bending  to  the  side  of  the  anterior  edge  of  the  cartilage,  even 
though  there  is  but  little  deflection  farther  back.  More  or  less  difficulty 
in  nasal  respiration  is  experienced  according  to  the  amount  of  obstruc- 
tion. Interference  with  the  free  passage  of  air  through  the  obstructed 
side  causes  the  secretion  to  collect  behind  the  convex  portion  and  in 
the  naso-pharynx,  giving  rise  to  postnasal  catarrh.  Pressure  upon  the 
external  wall,  especially  when  this  is  associated  with  exostosis,  often  in- 
duces atrophy  of  the  turbinated  body  of  that  side,  whereas  the  inferior 
turbinated  body  of  the  other  side  is  usually  hypertrophied ;  and  thus  it 
frequently  happens  that  patients  find  respiration  easier  through  the 
cavity  which  upon  inspection  seems  most  obstructed.  As  further  conse- 
quences of  the  obstruction,  the  voice  acquires  a  nasal  twang, and  mouth- 
breathing  becomes  necessary,  with  all  its  attendant  evils. 

Diagnosis. — There  is  no  disease  with  which  deflection  of  the  septum 
is  liable  to  be  confounded  if  a  careful  rhinoscopic  examination  is  made. 

Pkognosis. — Most  of  the  evil  results  of  the  obstruction  can  be  reme- 
died by  a  suitable  operation,  and  the  external  deformity  may  be  largely 
removed  if  the  nasal  bones  have  not  been  crushed  so  as  to  cause  depres- 
sion of  the  bridge  of  the  nose. 

Tkeatment. — The  simplest  treatment  that  has  been  recommended 
is  for  the  patient  to  push  the  nose  or  the  septum  firmly  over  to  the  op- 
posite side  several  times  daily ;  but  unfortunately  this  is  seldom  capable 
of  accomplishing  any  good. 

In  1851  Chassaignac  recommended  a  form  of  treatment  especially 
applicable  to  deviations  with  thickening  of  the  cartilaginous  septum. 
This  consisted  in  dissecting  up  the  mucous  membrane  and  paring  off 
the  superfluous  tissue.  It  is  not  always  easy  of  accomplishment,  but  in 
certain  cases  no  better  operation  could  be  devised.  Blanden  first  ad- 
vocated punching  out  a  portion  of  the  septum  and  establishing  free  con- 


596  DISEASES  .OF  THE  NASAL   CAVITIES. 

nection  between  the  two  nares  (Compendium  de  Chirurgie  Pratique, 
Tome  III),  but  tbis  does  not  afford  the  desired  relief  and  cannot  be 
recommended.  Walsham  proposes  forcible  replacement  of  the  bent 
septum  (Nelaton:  Pathologie  Chirurgicale,  seconde  edition,  Tome 
III),  its  resiliency  having  first  been  overcome  by  stellate  incisions. 
This  practice  has  been  effectual  in  moderate  deviations  of  the  septum 
without  thickening.  Where  the  deviation  is  marked,  the  redundant 
tissue  must  be  removed  in  order  to  obtain  perfect  results.     In  slight 


Fig.  318.— Ingals'  Septum  Forceps  G*a  size;. 

deviations  most  excellent  results  may  be  attained  by  making  a  crucial 
incision  through  the  cartilage,  the  cut  being  made  obliquely  so  that  the 
bevelled  edges  will  easily  slide  past  each  other.  The  septum  is  then 
forced  into  its  normal  position  by  forceps  (Fig.  218),  the  vomer  being 
fractured  if  necessary,  and  a  gutta-percha  plug  of  sufficient  size  is  kept 
in  the  obstructed  nostril  until  union  has  taken  place.  Where  the  stellate 
incisions  are  made  either  by  knife  or  punch,  the  plug,  or  Adam's  clamp, 
must  be  worn  in  a  similar  manner;  the  plug  is  simpler  and  quite  as 
effective.  In  most  instances  it  will  be  found  necessary  to  remove  the  re- 
dundant tissue  before  a  good  result  can  be  obtained.  In  cases  where  the 
cartilage  is  bent,  almost  at  right  angles,  across  the  nostrils,  I  have  found 
it  most  satisfactory  (as  I  stated  in  Transactions  American  Laryngological 
Association,  1880)  to  dissect  up  the  mu cous. membrane,  remove  a  triangu- 
lar piece  from  the  cartilage  of  sufficient  size,  incise  the  cartilage  farther 


Fig.  219.— Ixgals'  Septum  Knife  (2-5  size). 

back  to  destroy  its  resiliency,  and  then  place  a  plug  in  the  obstructed  nos- 
tril to  maintain  the  septum  in  position  until  union  has  taken  place.  When 
the  obstruction  is  less  complete,  and  there  is  simple  deviation  of  the  sep- 
tum, I  have  frequently  operated  by  making  three  or  four  horizontal  inci- 
sions through  the  cartilage  from  the  front  backward,  the  cut  being  made 
obliquely  from  above  downward^  and  outward;  sometimes  across  these 
near  the  middle  is  made  an  oblique  vertical  incision;  the  whole  is  then 
pushed  over  and  retained  by  a  plug  or  tube  of  gutta-percha  until  union 
has  occurred.  The  main  objection  to  this,  and  to  other  operations  in 
which  no  tissue  is  removed,  is  that  certain  parts  remain  thickened  and 


ECCHONDROMA  AND  EAr08T0SIS.  597 

the  resiliency  of  the  cartilage  is  seldom  perfectly  destroyed;  the  plug 
then  has  to  be  worn  for  several  weeks,  and  when  removed,  in  many  in- 
stances, the  cartilage  will  again  return  so  far  toward  its  old  position  as 
to  prevent  a  satisfactory  result.  During  the  past  two  years  I  have  fre- 
quently operated  on  these  cases  by  cutting  through  from  the  front 
backward,  in  three  or  four  places,  and  as  much  as  possible  beneath  the 
mucous  membrane,  with  a  small  trephine  about  two  and  one-half 
millimetres  in  diameter  (Fig.  202).  The  removal  of  these  cores  de- 
stroys the  resiliency  of  the  cartilage  so  that  it  may  be  readily  carried 
back  and  retained  in  its  proper  position.  Whatever  operation  is  adopted 
it  is  undesirable  to  perforate  the  cartilaginous  septum  because  of  the 
subsequent  tendency  of  the  secretions  to  dry  about  the  edges  of  the 
opening  and  form  obstructive  crusts  which  are  a  constant  annoyance  to 
the  patient.  Perforations  of  the  bony  septum  give  rise  to  little  or  no 
inconvenience,  provided  they  are  as  far  as  an  inch  back  of  the  nostril, 
in  which  position  the  edges  are  kept  moistened  by  the  secretions,  and 
scabs  do  not  collect. 

When  deformity  of  the  nose  and  obstruction  to  respiration  result 
from  protrusion  to  one  side  of  the  anterior  edge  of  the  triangular  carti- 


Fig.  520.— Ingals1  Right-Angle  Cutting-Forceps  Q/§  size). 

lage,  the  most  satisfactory  operation  consists  of  incising  the  mucous 
membrane,  over  the  edge  of  the  cartilage,  dissecting  it  back  upon  both 
surfaces,  and  then  cutting  off  with  a  right-angle  cutting-forceps  (Fig. 
220)  all  of  the  cartilage  that  projects  beyond  the  normal  plane  of  the 
septum  into  the  obstructed  nostril.  This  operation  not  only  relieves 
obstructed  respiration,  but  largely  remedies  the  external  deformity  or 
twisting  of  the  nose. 

In  order  to  secure  sufficient  anesthesia  for  this  operation  with  co- 
caine, it  will  be  necessary  to  inject  a  few  drops  of  a  weak  solution  (Form. 
140)  under  the  integument  on  the  outer  surface  of  the  cartilage;  the 
mucous  membrane  on  its  posterior  surface  being  anaesthetized  in  the 
usual  manner. 

ECCHONDROMA  AND  EXOSTOSIS  OF  THE  NASAL  SEPTUM. 

Ecchondroma  and  exostosis  of  the  nasal  septum  consist  of  thicken- 
ing of  the  cartilaginous  and  bony  parts  of  the  septum  with  a  more  or  less 
prominent  outgrowth  or  spur  in  most  cases,  and  usually  some  deflection. 
They  are  present  in  nearly  all  cases  of  deflected  septum,  and  the  etiology 
and  symptomatology  are  practically  the  same  in  both.  The  project- 
ing spur  is  usually  directed  from  below  upward   and   backward  along 


DISEASES   OF  THE  NASAL  CAVITIES. 

the  Hue  of  articulation  between  the  vomer  and  the  perpendicular  plate 
of  the  ethmoid.     This  may  be  small,  or  so  large  as  to  impinge  against 
outer  wall  of  the  nasal  cavity.     The  spur  is  covered  by  mucous 
membrane,  its  anterior   portion  is  cartilaginous, 
the  posterior  bony,  ami  the  inferior  part  immedi- 
ately back  of  the  cartilaginous  septum   is  made 
up  of  bone  of  extreme    hardness.     These  forma- 
tions, because  larger  and  exerting  more  pressure 
against  the  outer  wall,  are  more  liable  than  simple 
deviations  of  the  septum  to  excite  neuralgic  pain 
and  various  other  nervous  symptoms.     They  are 
frequently  found  in  cases  of  hypertrophic  rhinitis, 
Fig.  221.  — Ecchondroma   ]iav  fPVer,  astlima,  and  persistent  supra-orbital  or 

and     Exostosis    of    Right  - .     ,  x 

Side  of  Septum.    Hypertro-    Occipital  neuralgia, 

phy  of  inferior  turbinated         Diagxosis.— The  diagnosis  is  easilv  made  by 

body  of  left  si. In.  .  ...  ,      .  ,.       ,.  , 

inspection  of  the  nares  and  the  application  of  a 
probe,  which  detects  the  difference  in  the  density  of  simple  thickening 
of  the  soft  tissue,  and  that  of  bony  or  cartilaginous  tissue. 

Prognosis. — The  obstruction  may  be  completely  removed  by  suita- 
ble operation,  and  many  of  the  symptoms  will  be  relieved  accordingly; 
but  the  surgeon  should  not  be  too  confident  of  the  result,  for  in  a  con- 
siderable number  of  cases,  some  of  the  symptoms  will  remain. 

Treatment. — The  excessive  tissue  must  be  removed  by  operation, 
during  which  an  effort  should  be  made  to  save  as  much  of  the  mucous 
membrane  as  possible.  Before  commencing  the  operation,  the  septum, 
both  upon  the  affected  side  and  upon  the  opposite  side,  and  all  other 
portions  of  the  walls  of  the  cavity  liable  to  be  touched  during  the 
operation  should  be  thoroughly  anaesthetized  by  cocaine.  It  will  be  found 
impossible  to  produce  complete  anaesthesia  by  applying  cocaine  to  the  sur- 
face near  the  nostrils,  therefore  when  the  operation  is  to  extend  far  for- 
ward a  few  drops  of  the  solution  (Form.  140)  should  be  injected  beneath 
the  mucous  membrane  where  it  joins  the  integument,  Ecchondroma  near 
the  nostril  may  be  removed  by  dissecting  up  the  mucous  membrane  and 
paring  away  the  cartilage  with  a  knife,  or  cutting  it  with  saws,  trephines, 
or  drills.  Jarvis  has  devised  a  drill  for  cutting  cartilage  beneath  the 
mucous  membrane,  but  I  have  not  seen  its  work.  C.  H.  Wright,  a  den- 
tist of  Chicago,  had  made  for  me  a  burr  which  cuts  cartilage  very  well 
in  adults,  but  it  will  not  cut  mucous  membrane  except  under  firm  pres- 
sure, and  unfortunately  does  not  accomplish  much  on  cartilage  in  chil- 
dren. This,  or  other  drills  or  trephines  (Fig.  202)  I  use  with  an  electric 
motor.  The  burr  may  be  made  to  penetrate  the  mucous  membrane  by  firm 
pressure  while  it  is  in  motion;  and  then,  by  moving  it  slowly  about,  the 
excess  of  cartilaginous  or  bony  tissue  may  be  cut  away  without  injuring 
the  mucous  covering.  Any  of  the  debris  which  is  not  extruded  during 
the  drilling  process  is  washed  away  with  a  two  per  cent  solution  of  car- 


ECCHONDROMA  AND  EXOSTOSIS. 


599 


bolic  acid,  applied  by  a  small  syringe.     Ordinary  dental  burrs  will  not 
cut  cartilage.     Trephines  may  be  run  directly  through  from  the  front 


Fig.  222.— Sajous1  Knife  (]4  size). 


backward,  and  with  care  most  of  the  mucous  membrane  may  be  preserved, 
but  more  of  it  is  destroyed  than  when  a  burr  is  employed.     For  re- 


Fig.  223. — Nasal  Spud  (}/2  size). 


moval  of  ecchondroma  or  exostosis  situated  farther  back,  I  cut  the 
mucous  membrane  along  the  lower  edge  of  the  spur  with  Sajous'  knife 


Fig.  224. — Ingals'  Nasal,  Saw  (J^size). 


(Fig.  222),  and  bring  the  incision,  in  a  curved  line,  forward  and  upward 
to  the  anterior  and  upper  portion  of  the  mass  to  be  removed.     The 


Fig.  225. — Ingals'  Flat  Nasal  Saw  (2-5  size). 


mucous  membrane  is  then  lifted  from  the  subjacent  tissues  by  the  back 
of  the  same  instrument  or  a  spud  (Fig.  223) ;  a  saw  is  passed  beneath 


Fig.  226.— Sajous'  Nasal  Saw  Q4  size).    Form  used  for  downward  cutting. 


Fig,  227 Sajous'  Nasal  Saw  (^  size),    Form  used  for  upward  cutting. 

the  loosened  flap  at  the  upper  part  of  the  spur,  and  a  cut  made  down- 
ward  on  the  normal  plane  of  the  septum  until  it  reaches  nearly  to  the 


tJOO 


DISEASES  OF  THE  NASAL  CAVITIES. 


lower  part  of  the  nasal  fossa;  a  narrow  saw  is  then  passed  beneath  the 
spur,  and  a  cut  made  directly  upward  to  meet  the  one  from  above.  After 
the  bone  is  cut  through,  it  may  be  held  by  soft  tissues,  and  these  are  cut 
by  scissors  (Fig.  200),  to  allow  removal  of  the  fragment.  Sometimes 
stronger  scissors,  as  shown  (Fig.  228),  will  be  needed.    Subsequently  with 


Fig.  228.— Ingals1  Heavy-Bone  Scissors  (V^size). 

bone  forceps  (Fig.  229)  any  sharp  spicule  are  cut  off.  In  some  instances 
I  find  it  preferable  to  cut  through  the  lower  portion  of  the  spur  with 
a  good-sized  trephine.  In  others  where  the  spur  is  not  large,  I  use  the 
trephine,  only  removing  one  or  more  cores  as  seems  desirable.  This 
latter  operation  is  usually  made  without  first  having  removed  the  mucous 
membrane,  and  the  cut  is  made  as  much  as  possible  beneath  it.     After 


Fig.  229.— Ingals'  Nasal-Bone  Forceps  (%  size). 

the  bone  is  removed,  the  loose  flap  of  mucous  membrane,  which  may 
have  been  saved  above,  is  pressed  down  smoothly  against  the  septum. 

The  patient  then  blows  out  the  blood;  the  cavity  is  freely  dusted 
with  a  powder  of  equal  parts  of  iodoform  and  boric  acid,  and,  while  the 
flap  is  held  in  position  with  the  nasal  spatula  (Fig.  230),  the  naris  is 
packed,  as  recommended  in  the  treatment  of  epistaxis,  either  with  a 


Fig.  230.— Ingals'  Nasal  Spatcla  (V2  size).  Sets  of  three  varying  in  width,  angle  of  45°.  Made  of  steel. 

strip  of  haemostatic  gauze  or  pledgets  of  lint.  This  tampon  the  patient 
is  directed  to  remove  at  the  end  of  sixteen  to  twenty-four  hours,  but 
sometimes  it  is  allowed  to  remain  two  or  three  days  provided  there  is 
no  offensive  odor  or  pain.  Subsequently  the  wound  is  kept  clean  and 
as  nearly  antiseptic  as  possible,  and  the  patient  is  directed  to  use  two  or 
three  times  a  day  a  powder  containing  from  twenty  to  fifty  per  cent  of 
iodol. 


PERFORATION  OF  THE  NASAL  SEPTUM.  0U1 

Healing  usually  takes  place  in  from  one  to  six  weeks,  according  to 
the  size  of  the  wound  produced,  and  it  is  often  remarkable  that  after  a 
few  months,  even  when  large  spurs  have  been  removed,  the  membrane 
over  the  wound  appears  normal  with  no  cicatrix  that  can  be  seen.  H. 
Holbrook  Curtis  prefers  to  remove  these  spurs  with  the  trephine 
alone;  Bosworth  usually  employs  saws;  others  are  in  favor  of  dentrJ 
burrs.  By  using  a  trephine  to  cut  the  lower  portion,  where  the  bone  is 
very  hard,  and  a  saw  for  the  upper  part  of  the  incision  when  the  spur  is 
large,  I  am  enabled  to  make  the  most  complete  and  expeditious  opera- 
tion. The  main  objection  to  operating  with  the  trephine  alone  is  that 
after  making  two  or  three  cuts  it  will  be  found  that  sufficient  tissue  has 
not  been  removed,  and  the  parts  are  so  obscured  by  bleeding  that  it  is 
difficult  to  complete  the  operation  accurately;  it  therefore  requires 
much  more  time  than  with  the  saw;  in  the  mean  time  the  effects  of  the 
cocaine  are  liable  to  pass  away,  and  much  pain  will  be  caused.  Perfora- 
tion of  the  cartilaginous  septum  should  always  be  avoided,  and  an  open- 
ing should  not  be  made  in  the  bony  septum  if  sufficient  room  can  be 
obtained  without  it;  but  often  when  there  is  a  sharp  deflection,  together 
with  the  exostosis,  it  is  impossible  to  free  the  nostril  without  opening 
through  to  the  other  side.  There  is,  however,  no  serious  objection  to 
this,  providing  it  is  more  than  an  inch  back  from  the  nostril,  and  the 
opening  in  such  cases  is  certainly  preferable  to  a  cavity  only  one- third 
or  one-half  its  normal  size.  Cartilage  may  be  removed  by  electrolysis, 
preferably  performed  with  both  needles  introduced  into  the  tissue  near 
each  other. 

A  current  is  used  of  from  5  to  15  M.A. ,  continued  when  the  patient 
can  bear  it,  for  ten  or  fifteen  minutes  at  each  sitting.  The  operation  is 
not  repeated  until  the  eschar  is  thrown  off.  James  E.  Newcomb,  of  New 
York  {Medical  Record,  August  5,  1893),  who  has  recently  gone  over  this 
entire  subject  thoroughly,  concludes  that  the  method  is  worthy  of  a 
further  trial,  but  that  "  whatever  can  be  done  by  electrolysis  can  be,  by 
other  means,  accomplished  more  quickly."  In  most  instances  cauteriza- 
tion of  the  inferior  turbinated  body  of  the  opposite  side  will  subsequently 
be  found  necessary,  and  sometimes  it  is  desirable  to  remove  during  the 
operation  a  part  of  the  inferior  turbinated  body  of  the  same  side.  When 
the  operation  is  finished,  the  cavity  should  be  perfectly  free  and  about 
one- third  larger  than  normal,  to  allow  for  the  partial  closure  which  is 
sure  to  take  place  during  cicatrization. 

PERFORATION  OF  THE  NASAL  SEPTUM. 

Perforation  of  the  septum  is  often  found  as  a  result  of  syphilis,  but 
it  also  not  infrequently  occurs,  in  persons  of  low  vitality,  as  a  result  of 
constant  picking  at  the  nose;  or  it  may  happen  during  an  exhausting 
disease,  as  typhoid  fever,  pneumonia,  and  phthisis.     I  have  known  quite 


602  DISEASES  OF  THE  NASAL   CAVITIES. 

a  large  piece  of  the  cartilaginous  septum  to  be  expelled,  without  warn- 
ing, in  a  person  apparently  in  perfect  health;  and  I  have  even  seen  such 
openings  independent  of  any  of  the  causes  already  mentioned,  which 
have  occurred  without  the  patient's  knowledge. 

Treatment. — The  treatment  consists  in  making  suitable  applica- 
tions to  heal  any  ulceration  which  may  be  present.  It  is  not  worth 
while  to  try  to  close  the  opening,  an  attempt  which  even  at  best  could 
give  little  benefit,  and  which  would  usually  result  in  failure. 

HEMATOMA   OF  THE   NASAL  SEPTUM. 

Hematoma  is  a  collection  of  blood  in  the  septum  indicated  by  the 
formation  of  a  tumor  usually  at  the  lower  anterior  part,  and  projecting 
alike  upon  both  sides;  it  results  from  an  effusion  of  blood  between  the 
deep  layer  of  the  mucous  membrane  and  the  underlying  cartilage. 

Etiology. — Bare  cases  of  spontaneous  hematoma  have  been  ob- 
served, but  it  is  usually  due  to  fracture  of  the  bony  or  cartilaginous 
septum  by  violent  blows  on  the  nose. 

Symptomatology. — The  blood  collects  immediately  or  within  a  few 
hours  after  the  causative  accident,  and  causes  a  smooth,  uniform  tumor 
of  purple  color,  which  hue  sometimes  extends  to  a  considerable  portion 
of  the  mucous  membrane  of  the  nose.  These  tumors  are  situated  just 
within  the  nostril,  are  soft  and  fluctuating,  usually  symmetrical  upon 
both  sides,  and  may  be  so  large  as  to  protrude  from  the  nostrils.  More 
commonly  they  cause  simply  an  extremely  thickened  appearance  of  the 
cartilaginous  septum. 

Diagnosis. — The  tumors  are  liable  to  be  mistaken  for  mucous 
polypi,  hypertrophy  of  the  turbinated  body,  ecchondroma,  or  abscess  of 
the  septum.  The  essential  points  in  the  diagnosis  are  the' symmetrical 
character  of  the  swelling,  the  color,  and  the  fluctuation. 

These  tumors  are  distinguished  from  cartilaginous  tumors  by  their 
softness  and  symmetrical  appearance;  from  mucous  polypi  by  their  uni- 
form character,  broad  base,  and  color ;  from  extreme  hypertrophy  of  the 
anterior  end  of  the  inferior  turbinated  body,  by  their  location  in  the  sep- 
tum, as  demonstrated  by  the  probe;  from  abscess  by  their  color  and  by 
the  result  of  exploratory  puncture. 

Prognosis. — The  enlargements  sometimes  exist  for  a  long  time, 
but  usually,  within  a  few  days,  they  eventuate  in  abscess,  the  patient 
rarely  recovering  without  a  permanent  aperture  in  the  septum. 

Treatment.— Cold  applications  to  reduce  the  swelling  and  inflam- 
mation should  be  made  at  first;  if  the  blood  does  not  become  absorbed, 
as  sometimes  happens,  within  three  or  four  days,  it  is  apt  to  become 
purulent,  and  the  swelling  must  then  be  opened  upon  one  side  at  its 
most  dependent  part.  Usually  a  single  opening  will  drain  both  sides, 
but  an  incision  on  each  side  may  be  necessary. 


FOREIGN  BODIES  IN  THE  NOSE.  603 

ABSCESSES    OF   THE   NASAL   SEPTUM.  ' 

Abscesses  of  the  nasal  septum  may  be  acute  or  chronic.  They  are 
found  in  the  same  position  as  the  haematoma  just  described.  They 
may  result  from  the  latter,  or  follow  from  simple  inflammation  of  the 
parts.  The  symptoms,  diagnosis,  prognosis,  and  treatment  are  essen- 
tially the  same  as  those  of  haematoma  of  the  septum. 

FOREIGN   BODIES  IN   THE  NOSE. 

Foreign  bodies  of  great  variety  have  been  found  in  the  nose  where 
they  are  most  commonly  placed  by  children  in  play.  Beans,  peas,  buttons, 
or  pebbles,  are  most  common.  Insane  people  frequently  insert  things 
into  the  nares.  Occasionally  some  of  the  contents  of  the  stomach  are 
lodged  in  the  nose  during  the  act  of  vomiting.  I  have  seen  one  in- 
stance where  a  child,  during  the  act  of  deglutition,  choked  and  coughed, 
thus  lodging  in  the  posterior  naris  a  cervical  vertebra  of  a  chicken, 
which  remained  there  several  months. 

Symptomatology. — foreign  bodies  sometimes  remain  in  the  nose 
for  a  long  time  without  exciting  any  symptoms.  Substances  which 
absorb  moisture  soon  swell  and  obstruct  the  nostril,  and  beans,  peas, 
and  other  seeds  may  germinate.  Irregular  bodies  may  excite  acute  and 
severe  inflammation.  Headache,  often  assuming  a  neuralgic  form, 
is  occasionally  present  at  an  early  period.  The  most  characteristic 
symptom  is  a  more  or  less  profuse  discharge  from  one  nostril,  which 
becomes  exceedingly  offensive  when  the  body  is  one  which  will  take  up 
moisture  and  decompose.  Upon  inspection,  the  nasal  fossa  usually 
appears  filled  with  secretion,  .but  when  this  is  wiped  away  the  foreign 
body  may  be  seen,  or  felt  with  the  probe. 

Diagnosis. — The  presence  of  a  foreign  body  is  to  be  distinguished 
from  exostosis,  rhinoliths,  other  causes  of  nasal  obstruction,  and  from 
simple  catarrh,  by  the  history,  which  may  oftentimes  be  obtained  from 
the  child  or  its  playmates ;  by  the  occurrence  of  the  discharge  from  one 
side  only,  which  does  not  occur  in  simple  catarrhal  inflammation  of 
the  nasal  mucous  membrane;  by  the  offensive  nature  of  the  discharge 
in  many  instances;  and  by  careful  inspection  or  palpation  with  the 
probe.  As  an  illustration  of  the  difficulty  which  sometimes  attends 
the  diagnosis,  I  recall  an  instance  in  which  a  long  match  had  been 
inserted  into  the  nose  and  had  been  sought  unsuccessfully  by  a  phy- 
sician. The  mucous  membrane  was  so  swollen  and  the  naris  so  filled 
with  secretion  that  the  object  was  found  only  after  carefully  wiping 
this  away,  and  feeling  backward  with  the  probe  along  the  floor  of  the 
nasal  fossa.  Since  the  discovery  of  the  properties  of  cocaine,  it  is  much 
easier  to  make  a  diagnosis  in  these  cases,  for  by  the  injection  of  a  small 


604  DISEASES  OF  THE  NASAL   CAVITIES. 

quantity  of  this  drug  the  swelling  is  removed  and  the  mucous  membrane 
is  benumbed  so  that  a  careful  exploration  can  be  made.  A  good  light 
is  always  essential  to  a  satisfactory  examination. 

Foreign  bodies  are  distinguished  f rom polypi  by  their  color,  consist- 
ence, and  mobility;  from  exostosis  in  the  same  way. 

Prognosis. —  Small  bodies  may  remain  for  a  long  time,  even  many 
years,  without  attracting  attention.  By  the  accretion  of  chalky  de- 
posits they  may  become  the  nuclei  of  rhinoliths.  They  are  not  danger- 
ous, but  in  most  instances  sooner  or  later  provoke  an  extremely  offensive 
discharge. 

Treatment. — The  nasal  cavity  should  be  anaesthetized  with  cocaine, 
and  the  substance  removed  with  forceps,  catheter,  probe,  hooks,  screws, 
posterior  nasal  douche,  or  the  snare;  the  latter  I  have  found  more  use- 


Fig.  231. — Gross'1  Instruments  for  Removing  Foreign  Bodies  from  the  Nasal  Cavities  and  Ears. 

ful  than  other  instruments.  The  loop  is  easily  passed  by  the  sides  of 
the  foreign  body,  and  when  tightened  upon  it  the  object  is  firmly  held  so 
that  it  can  be  withdrawn.  In  one  instance  I  extracted  by  this  means 
a  wild  tooth  from  the  floor  of  the  naris  which  had  caused  a  catarrhal 
discharge  for  several  years. 

RHINOLITHS. 

Rhinoliths  are  cretaceous  masses  of  comparatively  rare  occurrence 
which  usually  owe  their  origin  to  the  lodgment  in  the  naris  of  some 
foreign  substance  upon  which  phosphate  of  lime  is  gradually  deposited 
from  the  secretions.  They  are  generally  hard  on  the  surface,  but  softer 
toward  the  centre. 

Symptomatology. — The  symptoms  are  similar  to  those  described  as 
due  to  the  presence  of  foreign  bodies,  the  most  characteristic  being  ob- 
struction and  a  fetid  discharge  from  one  nostril.  "When  situated  in  the 
upper  and  anterior  portion  of  the  nasal  fossa,  they  sometimes  cause 
swelling  of  the  face.  The  symptoms  come  on  more  slowly  than  those  re- 
sulting from  a  foreign  body;  but  as  the  calculus  continually  enlarges,  the 
obstruction  finally  becomes  greater.  The  calculus  is  usually  single,  but 
more  than  one  may  occasionally  be  found.  It  is  generally  of  a  grayish  or 
blackish  color,  with  a  rough,  and  more  or  less  uneven  though  sometimes 
smooth  surface.  Sometimes  it  becomes  partially  imbedded  in  the 
mucous  membrane,  which  then  is  apt  to  ulcerate  and  bleed.  The  size 
of  the  calculus  varies  greatly.  TV.  X.  Browne  records  a  case  (Edin- 
burgh Medical  Journal,  1859)  in  which  the  stone  measured  one  inch  and 
three-quarters  in  length,  one  inch  in  breadth,  and  nearly  half  an  inch 
in  thickness. 


MYASI8  NARIUM.  605 

Diagnosis. — A  rhinolith  may  be  confounded  with  osteoma  or  can- 
cer. It  is  distinguished  from  osteoma  in  that  it  is  movable  and  can  be 
penetrated  by  a  sharp  probe  or  needle.  Owing  to  the  fungoid,  bleed- 
ing granulations  which  sometimes  spring  up  from  the  edges  of  the 
mucous  membrane,  where  ulceration  has  occurred,  and  also  to  the  offen- 
sive discharge,  it  may  be  mistaken  for  cancer,  from  which  it  is  dis- 
tinguished by  its  slow  growth,  the  comparative  absence  of  pain,  and  by 
inspection  and  palpation  with  the  probe. 

Prognosis. — Ehinoliths  may  remain  many  years,  causing  much  an- 
noyance, but  they  are  not  dangerous  to  life. 

Treatment. — Iihinoliths  may  usually  be  removed  with  joolypus 
forceps  or  the  snare,  or  they  may  sometimes  be  crowded  back  into  the 
naso-pharynx,  when  they  will  be  expelled  by  the  patient.  If  too  large 
to  be  readily  removed,  they  should  be  broken  down  with  the  nasal  bone 
forceps  (Fig.  229). 

MTASIS  NARIUM. 

Synonym. — Maggots  in  the  nose. 

Myasis  narium  is  a  condition  very  rare  excepting  in  the  tropics.  It 
is  characterized  by  destruction  of  the  soft  tissues  and  occasionally  of  the 
bone,  with  offensive  discharge,  formication,  severe  pain,  insomnia,  and 
sometimes  convulsions.  It  has  been  frequently  observed  in  British 
India,  South  America,  and  Mexico,  but  in  those  countries  it  is  said  not 
to  be  found  in  the  cooler  atmosphere  of  high  altitudes.  Very  few  cases 
have  been  recorded  either  in  Europe  or  the  United  States.  A  case  is 
recorded  by  D.  N.  Eankin  (Transactions  of  the  American  Laryngological 
Association,  1883). 

Etiology. — Usually  the  worms  owe  their  presence  to  the  hatching 
of  eggs  deposited  in  or  near  the  nostril  by  flies,  which  are  attracted  by 
the  odor  of  an  already  existing  discharge  or  foul  breath. 

Symptomatology. — Soon  after  deposit  of  the  eggs,  the  mucous  mem- 
brane becomes  irritable,  tickling  sensations,  with  attacks  of  sneezing,  soon 
follow,  and  subsequently  troublesome  crawling  sensations  are  experi- 
enced. There  is  a  sanious  or  bloody  discharge  from  the  nostrils,  and 
oedema  of  the  face  and  eyelids  may  also  appear;  severe  and  sometimes  ex- 
cessive, unceasing,  pain  is  felt  at  the  root  of  the  nose  and  over  the  frontal 
region.  In  this  affection  the  mucous  membrane,  and  even  the  carti- 
lages and  bones,  may  be  destroyed,  and  the  resulting  inflammation  may 
extend  to  the  brain,  causing  convulsions  and  death.  As  many  as  two  or 
three  hundred  maggots  have  been  ejected  from  the  nose  in  a  single  case. 
Upon  inspection,  the  horrible  condition  may  be  readily  detected. 

Diagnosis. — All  the  symptoms  may  be  caused  by  other  affections, 
therefore  the  diagnosis  must  depend  upon  finding  maggots  in  the  nasal 
cavity. 

Prognosis. — If  neglected,  a  considerable  proportion  of  cases  will 
eventually  prove  fatal. 


606  DISEASES  OF  THE  NASAL  CAVITIES. 

Treatment.— Chloroform  has  been  found  most  efficient  for  destruc- 
tion of  the  parasites.  In  some  instances  inhalation  only,  of  chloroform 
is  sufficient  to  effect  a  cure.  When  this  does  not  succeed,  the  patient 
should  be  fully  anaesthetized,  and  the  nasal  cavities  thoroughly  syringed 
with  pure  chloroform.  This  does  not  seem  to  affect  the  mucous  mem- 
brane deleteriously,  but  it  would  cause  extreme  pain  if  the  patient  were 
conscious. 


CHAPTER  XXXYI. 

DISEASES   OF   THE   NASO-PHARYNX. 

RHINO-PHARYNGITIS. 

Synonyms. — Post-nasal  catarrh,  retro-nasal  catarrh,  follicular  disease 
of  the  naso-pharynx. 

Rhino-pharyngitis  consists  of  chronic  inflammation  of  the  mucous 
membrane  of  the  naso-pharynx,  characterized  by  collection  of  viscid  or 
drying  secretion,  and  a  tendency  to  hawk  frequently  and  clear  the 
throat,  especially  in  the  early  morning  or  after  eating.  It  is  a  very 
common  and  widespread  affection,  but  seems  especially  prevalent  in 
America,  where  it  is  found  in  all  regions  and  among  patients  of  differ- 
ing age,  sex,  and  condition;  it  is  less  frequent  in  warm  and  equable  cli- 
mates. 

Etiology. — Beverley  Robinson  justly  attributes  it  largely  to  cold 
and  damp  atmosphere  subject  to  sudden  and  great  changes  of  tempera- 
ture, but  believes  that  it  is  also  due  to  a  special  diathesis  which  he  terms 
catarrhal  (Nasal  Catarrh,  1880).  Mackenzie  believes  it  is  mainly  due 
to  dust,  and  frequently  to  dyspepsia.  I  am  satisfied  that  a  cold,  damp 
climate,  and  an  excessive  amount  of  irritating  dust  in  the  atmosphere, 
are  the  chief  of  its  predisposing  causes,  and  that  disturbance  of  the 
digestive  organs  is  a  pronounced  etiological  factor  in  many  instances; 
but  I  am  equally  satisfied  that  obstruction  of  the  nares,  as  in  hyper- 
trophic rhinitis,  is  the  exciting  cause  in  a  large  proportion  of  cases; 
while  in  certain  others  the  affection  is  due  to  extension  of  inflammation 
from  the  nares  or  oro-pharynx.  Hypertrophy  of  Luschka's  tonsil 
or  even  of  the  faucial  tonsils  undoubtedly  causes  the  disease  in 
some  cases;  but  the  catarrhal  symptoms  caused  by  hypertrophy  of 
Luschka's  tonsil,  or  excessive  adenoid  growths  in  the  naso-pharynx, 
should  not  be  confounded  with  the  result  of  simple  inflammation. 
Tornwaldt  contends  that  it  is  often  due  to  catarrhal  inflammation  of 
the  pharyngeal  bursa  (Ueber  die  Bedeutung  der  Bursa  pharyngea,  u.  s.  w., 
Wiesbaden,  1885);  this  is  undoubtedly  true  of  some  cases,  but  not 
of  a  large  percentage.  Many  cases  are  apparently  caused  by  sub- 
mucous thickening  at  the  sides  of  the  posterior  part  of  the  vomer. 
I  am  unable  to  explain  the  direct  relation  of  this  thickening  to  the  dis- 
charge and  chronic  inflammation,  but  I  am  satisfied  of  its  etiological 
relation  from  the  fact  that  its  reduction  will  often  greatly  benefit,  if  not 


608  DISEASES  OF  THE  NASOPHARYNX. 

completely  cure,  the  post-nasal  catarrh.  Tobacco-smoking  is  a  com- 
paratively frequent  cause,  and  the  excessive  use  of  alcoholic  stimulants 
may  produce  congestion  and  inflammation  of  the  mucous  membrane 
here  as  in  other  localities. 

Symptomatology. — In  slight  cases  the  patient  is  merely  troubled 
with  a  sensation  as  of  something  sticking  in  the  naso-pharynx,  but 
usually  the  secretion  is  tenacious  or  dry,  and  difficult  to  dislodge, 
and  gives  the  patient  great  discomfort,  causing  him  to  hawk  and 
make  frequent  efforts  at  its  removal.  Distinct  articulation  is  fre- 
quently prevented,  partially  from  obstruction  of  the  naso-pharynx  and 
partially  from  a  mild  form  of  chronic  laryngitis  which  often  coexists. 
These  conditions  are  most  annoying  early  in  the  morning  or  after  eating, 
when  the  patient's  efforts  to  dislodge  the  secretion  may  produce  nausea 
or  even  vomiting.  The  symptoms  are  especially  troublesome  in  damp 
or  chilly  weather,  or  after  catching  cold.  Dull  aching  in  the  upper  part 
of  the  throat,  and  sometimes  weight  and  pain  in  the  occipital  region, 
are  experienced  by  some  of  these  patients,  but  the  latter  is  apparently  due 
to  the  rhinitis  rather  than  to  the  pharyngitis.  The  sense  of  hearing  is 
often  obtunded,  in  consequence  of  extension  of  the  inflammation  through 
the  Eustachian  tube. 

Upon  examining  the  pharynx,  tenacious  secretion  will  usually  be 
observed  coming  down  from  the  naso-pharynx,  upon  the  vault  of 
wdiich  similar  secretion  or  adherent  crusts  may  be  found.  The  mu- 
ous  membrane  is  more  or  less  congested  and  usually  has  a  relaxed 
appearance,  often  exhibiting  one  or  more  enlarged  follicles,  especially 
just  back  of  the  posterior  pillars  of  the  fauces;  indeed,  in  many  in- 
stances this  affection  appears  to  be  simply  a  chronic  follicular  inflam- 
mation of  the  upper  part  of  the  pharynx  associated  with  a  similar  condi- 
tion in  the  oropharynx.  The  diseased  follicles  referred  to  appear  as 
small,  oval  or  round,  reddish  granulations,  usually  raised  about  two 
millimetres,  and  from  four  to  eight  millimetres  in  diameter.  Small  ero- 
sions or  ecchymotic  spots  are  sometimes  seen,  and  in  3*oung  subjects 
adenoid  growths  in  the  vault  are  frequently  present.  The  Eustachian 
orifices  are  often  congested  and  swollen  and  sometimes  blocked  with 
secretion.  Varicose  veins  are  often  observed  in  the  pharynx,  and 
the  pillars  of  the  fauces  are  usually  congested  and  thickened.  In  ad- 
vanced cases,  atrophy  occurs,  with  accompanying  dryness  and  irritation 
of  the  parts.  Whatever  the  condition,  there  is  apt  to  be  a  similar  affec- 
tion of  the  oro-pharynx. 

Diagnosis. — The  disease  may  be  confounded  with  adenoid  growths 
or  other  tumors,  or  syphilitic  disease  of  the  parts.  We  can  distinguish 
adenoid  and  other  growths  by  inspection  and  palpation,  and  syphilitic 
disease  by  a  consideration  of  the  history,  and  by  inspection,  which  is 
liable  to  reveal  mucous  patches,  condylomata,  ulcers,  or  cicatrices. 

Prognosis. — The  disease  may  extend  over  a  period  of  many  years, 


RHINOPHARYNGITIS.  609 

but  is  not  dangerous  to  life,  and,  contrary  to  the  popular  belief,  which  is 
fostered  among  the  laity  by  designing  charlatans,  there  appears  to  be  no 
tendency  for  it  to  extend  downward  and  eventuate  in  pulmonary  tuber- 
culosis. When  the  affection  has  lasted  for  many  years  it  is  doubtful 
whether  it  is  often  cured,  but  in  the  majority  of  cases  removal  of 
the  nasal  obstruction  will  greatly  relieve,  if  not  cure,  the  disease  in  the 
naso-pharynx. 

Tkeatmekt. — As  a  means  of  prophylaxis  the  patient  should  be  pro- 
tected so  far  as  possible  from  sudden  changes  of  weather;  he  should 
avoid  dampness  and  chills;  summer  and  winter  constantly  wear  woollen 
underclothes;  keep  the  skin  and  digestive  organs  vigorous  by  the  ob- 
servance of  proper  hygienic  rules,  and  when  exposed  to  an  excessive 
amount  of  dust  in  the  atmosphere,  protect  the  nares  and  pharynx  by 
wearing  loose  pledgets  of  wool  in  the  nostrils,  or  by  some  form  of 
respirator. 

The  treatment  of  this  disease  resolves  itself  in  the  main  into  curing 
the  nasal  disease  which  has  caused  it.     Constitutional  treatment  is  indi- 


Fig.  232.— Post-nasal  Syringe  (2-5  size). 

cated  for  debility,  and  faulty  digestion  must  be  corrected  by  appropri- 
ate treatment,  as  has  been  so  judiciously  insisted  upon  by  Beverley 
Eobinson  (Transactions  of  the  American  Laryngological  Association, 
Vol.  X).  In  the  direct  treatment  of  the  naso-pharynx,  cleanliness 
is  of  first  importance.  This  may  be  accomplished  by  means  of  the 
nasal  douche,  nasal  insufflation,  the  post-nasal  syringe  (Fig.  232),  or  the 
free  use  of  nasal  or  post-nasal  atomizers.  The  salicylate  wash  (Form. 
187)  is  an  excellent  detergent  application;  but  any  alkaline  wash,  as,  for 
example,  sodium  bicarbonate  or  equal  parts  of  sodium  bicarbonate  with 
sodium  chloride  3  i.  ad  0  i.  of  water,  or  Dobell's  solution  may  be  used 
instead.  It  should  always  be  borne  in  mind  that  with  the  nasal 
douche,  and  to  a  less  extent  even  with  the  other  methods  of  cleansing 
just  recommended,  there  is  some  danger  that  fluid  may  pass  through 
the  Eustachian  tube  to  the  middle  ear.  This  may  generally  be  avoided 
by  causing  the  patient  to  keep  the  mouth  open,  not  to  use  too  much 
force,  and  to  be  careful  not  to  swallow  while  the  application  is  being 
made.     The  solution  should  always  be  used  lukewarm. 

The  parts  having  been  cleansed,  Mackenzie  specially  recommends 
the  insufflation  of  astringent  powders.  The  old-time  application  of  a 
solution  of  silver  nitrate,  varying  in  strength  from  ten  to  sixty  grains  to 
the  ounce,  will  be  found  beneficial  in  many  cases;  and  astringent  or 
stimulating  sprays,  either  aqueous  or  oleaginous,  are  often  desirable. 
39 


€10  DISEASES  OF  THE  NASOPHARYNX. 

When  there  are  enlarged  follicles  without  great  congestion,  and  where 
the  parts  remain  moist,  I  have  seen  great  benefit  from  the  insufflation, 
two  or  three  times  per  week,  of  two  or  three  grains  of  a  powder  con- 
sisting of  berberine  muriate  one  part  and  sugar  of  milk  or  acacia  two 
parts.  For  excessive  secretion,  either  here  or  in  the  nares,  I  have  found 
terebene  beneficial  in  the  proportion  of  about  ten  minims  to  the  ounce 
of  liquid  albolene,  combined  or  not  with  other  substances  as  seems  de- 
sirable. If  the  parts  have  a  tendency  to  dryness,  after  they  have  been 
thoroughly  cleansed  the  application  of  an  oily  spray  containing  from 
two  to  six  grains  of  carbolic  acid  to  the  ounce  may  be  made  by  the 
patient  twice  daily  back  of  the  palate,  or  in  case  he  cannot  do  this  a 
weaker  spray  may  be  thrown  through  the  nose  while  the  head  is  held 
backward  so  that  it  will  run  gradually  down  over  the  pharyngeal  wall. 
Indeed,  the  same  remedies  are  applicable  here  as  to  the  nasal  cavities, 
it  being  remembered  that  the  naso-pharynx  will  tolerate  advantageously 
applications  from  fifty  per  cent  to  one  hundred  per  cent  stronger  than 
the  nasal  cavities. 

THROAT   DEAFNESS. 

Morbid  changes  in  the  naso-pharynx,  particularly  when  near  the 
orifice  of  the  Eustachian  tube,  frequently  involve  the  latter  and  extend 
to  the  middle  ear,  affecting  more  or  less  the  sense  of  hearing.  Probably 
most  cases  of  deafness  are  of  this  nature. 

Etiology. — The  disease  may  depend  upon  a  paretic  condition  of  the 
Eustachian  tube,  or  chronic  inflammatory  thickening  of  its  lining  mem- 
brane, or  any  morbid  state  of  the  naso-pharynx  which  gives  rise  to  ob- 
struction of  the  Eustachian  orifice.  Edward  Woakes  considers  this,  or 
motor  paralysis,  the  fundamental  cause  (Diseases  of  the  Nose).  He 
also  attributes  the  deafness  to  exaggerated  folds  of  mucous  membrane 
at  the  orifice  of  the  Eustachian  tube,  and  to  folds  projecting  from  the 
sides  of  the  pharynx,  and  to  partial  obstruction  of  the  nasal  cavity  by 
exostosis,  or  hypertrophy  of  the  turbinated  bodies;  whereby  during 
inspiration,  but  especially  deglutition,  the  air  is  rarefied  in  the  tym- 
panic cavity,  producing  depression  of  the  drumhead.  Persistence  of 
this  condition  eventuates  in  permanent  collapse  of  the  membrane  and 
resulting  deafness.  One  of  the  most  frequent  .causes  of  throat  deafness 
is  enlargement  of  Luschka's  tonsil.  Atrophic  rhinitis  is  also  a  cause; 
the  affection  has  also  been  attributed  to  syphilis,  diphtheria,  rheuma- 
tism, progressive  muscular  atrophy,  chlorosis,  and  extreme  anaemia. 

'  Symptomatology. — According  to  Weber-Liel,  the  chief  feature  of 
the  complaint  is  paralysis  of  the  tensor  palati  muscle  (Mackenzie: 
Diseases  of  the  Throat  and  Nose,  Vol.  II).  In  severe  cases  there  is  col- 
lapse of  the  Eustachian  tube,  the  air  in  the  tympanic  cavity  becomes 
rarefied  and  the  tympanic  membrane  yielding  to  the  pressure   of   the 


THROAT  DEAFNESS.  611 

denser  air  on  its  external  surface  becomes  abnormally  concave  (drawn 
in)  and  as  this  movement  of  the  drumhead  is  necessarily  transmitted  to 
the  chain  of  ossicles,  the  foot-plate  of  the  stapes  is  abnormally  pressed 
into  tHe  oval  fenestra.  Secondary  changes  soon  follow,  passive  conges- 
tion of  the  tympanic  cavity  leads  to  trophic  changes  of  a  more  or  less 
cirrhotic  character,  consisting  at  first  in  the  growth  of  a  low  form  of  con- 
nective tissue,  with  subsequent  atrophy.  Adhesion  takes  place,  the 
stapes  becomes  fixed  in  the  fenestra  ovalis,  and  the  labyrinth  becomes 
the  seat  of  disease.  The  patient  often  complains  of  tickling  or  scratch- 
ing sensations  in  the  throat;  of  snapping  sounds  heard  during  mastica- 
-rion  or  deglutition;  of  fatigue  in  listening,  and  difficulty  in  hearing 
during  general  conversation,  though  he  may  readily  understand  one 
person  talking  alone;  and  often  of  noises  in  the  head  and  giddiness. 

Diagnosis. — In  the  mildest  form,  according  to  E.  C.  Hotz,  pro- 
fessor of  ophthalmology,  Chicago  Polyclinic,  the  tympanic  membrane 
is  of  normal  color  and  brightness,  but  abnormally  concave  (personal 
letter  from  F.  G.  Hotz,  July,  1891).  In  the  medium  variety,  attended 
by  acute  inflammation  of  the  middle  ear,  the  membrane  is  congested  ac- 
cording to  the  degree  of  inflammation,  and  the  injection  may  be  limited 
to  a  small  streak  along  the  malleus  or  may  occupy  the  upper  flaccid 
portion  only,  or  it  may  spread  over  the  whole  membrane.  The  Eusta- 
chian tube  is  obstructed,  and  the  tympanic  cavity  contains  more  or  less 
secretion,  the  presence  of  which  is  indicated  by  characteristic  rales 
heard  through  the  auscultating  tube  while  insufflation  is  made  through 
the  Eustachian  catheter.  In  the  most  serious  variety,  the  drum  mem- 
brane may  be  bright  and  clear  or  dull  and  opaque,  its  movements  may 
be  impeded  indicating  sclerosis  or  anchylosis,  or  they  may  be  excessive, 
indicating  atrophy,  and  the  Eustachian  tubes  may  be  either  closed  or 
unusually  patent.  The  drum  cavity  may  be  either  dry  and  empty  or  it 
may  contain  inspissated  mucus,  and  we  must  distinguish  by  the  tuning- 
fork  test  whether  the  deafness  is  due  to  changes  in  the  middle  ear  or  to 
lesions  of  the  internal  ear.  If  the  patient  hears  the  sounding-fork  bet- 
ter when  placed  near  the  external  ear  than  when  touched  to  his  fore- 
head or  held  between  the  teeth,  we  must  assume  that  the  internal  ear  is 
involved;  but  if  the  fork  is  heard  better  against  the  forehead  or  between 
the  teeth,  we  conclude  that  the  chief  cause  of  deafness  is  located  in  the 
middle  ear. 

Prognosis. — In  the  mild  variety  the  prognosis  is  favorable  provided 
the  congestion  and  swelling  of  the  pharynx  and  Eustachian  tube  can  be 
removed  by  occasional  insufflation.  In  the  second  variety,  also,  the  prog- 
nosis is  good  if  proper  treatment  is  adopted  early;  but  if  neglected,  per- 
manent damage  to  the  structure  and  sense  of  hearing  is  likely  to  ensue. 
In  the  most  severe  or  chronic  form,  the  chances  for  cure  or  even  relief 
are  poor,  especially  when  the  tuning-fork  test  shows  that  the  internal 
ear  is  affected  :  but  even  in  these  cases  the  prognosis  is  somewhat  more 


012  DISEASES   OF  THE  NASO-PHARYNX. 

favorable  if  there  are  rales,  indicating  the  presence  of  mucus  in  the 
tympanic  cavity,  or  if,  as  sometimes  happens,  there  is  marked  and  fre- 
quent variation  in  the  hearing  power.  In  the  majority  of  cases  no  im- 
provement can  be  expected,  and  we  are  fortunate  if  by  treatment  we  can 
check  the  onward  progress  of  the  disease  and  save  the  patient  from  ab- 
solute deafness. 

Treatment. — Our  first  effort  should  be  directed  to  removing  the 
cause  of  the  disease.  Obstruction  of  the  naso-pharynx,  or  of  the  nares 
by  the  various  forms  of  inflammation  or  exostosis  or  tumors,  should  be 
removed  and  the  inflammation  subdued  by  the  methods  already  sug- 
gested. For  the  chronic  thickening  and  congestion  of  the  rhino- 
pharynx,  with  extension  to  the  Eustachian  tubes,  the  frequent  applica- 
tion of  strong  solutions  of  silver  nitrate,  varying  in  strength  from  forty 
to  one  hundred  and  twenty  grains  to  the  ounce,  have  been  most  highly 
recommended,  and  the  various  alteratives,  astringents,  and  stimulants 
already  recommended  may  be  tried.     In  a  considerable  number  of  cases 


Fig.  233.—  CCR"!'^  Vaporizer.  For  inflation  of  the  Eustachian  tubes  and  middle  ear.  The 
bottle  should  be  held  in  the  hand  with  the  thumb  alongside  the  glass  bulb.  When  applied  to  the 
nostrils,  the  thumb  completely  covers  one  and  the  glass  bulb  snugly  fits  the  other  orifice.  The 
right  hand  grasps  the  rubber  ball,  and  simultaneously  with  the  rapid  enunciation  of  the  letter  K  or 
the  guttural  G,  a  number  of  pressures  upon  the  bulb  will  inflate  the  middle  ear  without  the  trouble 
of  taking  a  swallow  of  water.  This  method  of  treatment  of  the  Eustachian  tubes  by  the  vapor  of 
iodine,  ether,  chloroform,  etc.,  dropped  upon  the  sponge  of  the  vaporizer,  is  reported  to  be  very 
efficacious  by  H.  Holbrook  Curtis.  By  removing  the  sponge,  the  instrument  may  be  used  as  a 
powder  blower. 

I  have  obtained  much  benefit  from  spraying  into  the  naso-pharynx  and 
'Eustachian  tubes,  while  the  nostrils  are  held,  a  solution  of  two  to  five 
grains  of  menthol  to  the  ounce  of  liquid  albolene.  This  may  be  readily 
done  by  the  Davidson  atomizer  No.  GG  with  the  long  tip  (Fig.  106),  and 
there  is  no  danger  in  using  fifteen  to  twenty  pounds  pressure,  for  the 
palate  will  yield  before  injury  will  be  done  to  the  drum  membrane.  As 
stated  by  Hotz,  in  addition  to  the  treatment  of  the  pharynx,  in  mild 
cases,  when  the  chief  trouble  is  the  insufficient  ventilation  of  the  tym- 
panic cavity  on  account  of  the  catarrhal  swelling  in  the  Eustachian  tube, 
it  is  only  necessary  every  two  or  three  days  to  supply  the  drum  cavity 
with  fresh  air  by  means  of  Politzer's  method.  But  when  the  tympanic 
cavity  itself  is  the  seat  of  catarrhal  changes  the  use  of  the  Eustachian 
catheter  is  indispensable  for  the  efficient  introduction  of  suitable  reme- 


HYPERTROPHY  OF  THE  PHARYNGEAL   TONSIL.  613 

dies.  When  the  auscultating  tube  reveals  the  presence  of  mucus  in  the 
Eustachian  tube  and  tympanic  chamber,  warm  solutions  of  boric  acid 
(gr.  x.  ad  3  i.)  are  very  serviceable.  Two  or  three  drops  of  this  are  put 
into  the  catheter  and  blown  into  the  cavity  by  means  of  the  air-bag.  In 
the  atrophic  forms  of  otitis  media,  stimulating  vapors  are  recommended, 
as  of  ammonium  muriate,  eucalyptol,  or  benzol 

In  cases  of  severer  grade  with  acute  inflammation,  he  specially 
recommends  hot  solutions  of  cocaine  four  per  cent,  frequently  dropped 
into  the  external  meatus,  and  warm  compresses  covering  the  ear  and 
mastoid  region,  together  with  careful  insufflations  through  the  Eus- 
tachian catheter  to  ventilate  the  drum  chamber  and  clear  it  of  accumu- 
lated mucous  secretions,  and  at  the  same  time  spraying  this  cavity 
through  the  catheter  with  solutions  of  boric  acid,  eucalyptus,  or  other 
suitable  remedies.  In  this  variety,  rapid  and  copious  secretion  into  the 
cavity  is  liable  to  take  place,  indicated  by  intense  pain  and  bulging  of 
the  membrane,  for  which  paracentesis  should  be  done  at  once.  In  the 
severer  forms  of  the  disease  the  local  applications  recommended  may 
be  tried,  but  not  much  can  be  accomplished.  Mackenzie  recommends 
constitutional  treatment  by  the  use  of  iron,  strychnine,  and  phos- 
phorus, and  suggests  that  in  the  later  stages  nothing  remains  but  the 
doubtful  operation  of  paracentesis  of  the  tympanum  or  tenotomy  of  the 
tensor  tympani  (Diseases  of  the  Throat,  Vol.  II). 

These  cases  are  most  unpromising,  and  it  is  only  by  carefully  adapt- 
ing the  treatment  to  the  requirements  and  the  peculiarities  of  each 
individual  patient  that  we  can  hope  to  jnevent  even  absolute  deafness. 
The  details  of  treatment  are  more  properly  set  forth  in  works  on  diseases 
of  the  ear,  and  the  treatment  itself  should  be  carried  out  by  an  experi- 
enced aurist. 

HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL. 

Synonyms. — Hypertrophy  of  Luschka's'  tonsil,  adenoid  growths  in 
the  vault  of  the  pharynx. 

An  abnormal  enlargement  of  the  glandular  tissue  normally  found  in 
the  vault  and  walls  of  the  pharynx,  is  characterized  by  obstruction  of 
nasal  respiration,  alterations  in  the  voice,  and  in  many  cases  partial 
deafness,  with  catarrhal  symptoms  and  more  or  less  deterioration  of  the 
general  health.  It  is  particularly  observed  in  damp  climates.  It  com- 
monly occurs  in 'children,  but  is  not  infrequently  observed  in  young 
adults. 

Anatomical  and  Pathological  Characteristics. — The  changes 
in  the  glandular  tissue  closely  resemble  those  which  are  frequently  wit- 
nessed in  the  faucial  tonsil.  The  gland  is  of  a  grayish  or  pinkish  color, 
though  sometimes  even  of  a  bright  red  hue,  and  the  surface  often  has 
a  lobulated  appearance.  Enlarged  blood  vessels  are  not  present  upon 
the  surface,  as  in  many  other  forms  of  abnormal  growth.     The  tissue 


614 


DISEASES  OF  THE  NA80-PHARYNX. 


may  be  soft  and  friable  (Fig.  234)  or  exceeding]}'  firm.  It  consists  of 
lymphoid  structure  and  increased  connective  tissue  similar  to  that 
found  in  hypertrophy  of  the  faucial  tonsil.  The  effect  upon  respiration 
and  the  general  health  depends  upon  the  size  and  the  amount  of  ob- 
struction. 

ETIOLOGY. — Heredity  evidently  bears  some  part  in  the  etiology  of 
the  affection,  although  statistics  have  not  yet  proven  the  point;  fre- 
quently several  children  in  the  same  family  will 
be  found  affected.  It  appears  to  be  due  in  most 
-  to  the  same  causes  as  enlargement  of  the 
faucial  tonsil.  The  exanthematous  diseases  and 
diphtheria  are  common  causes,  and  frequent 
colds,  as  well  as  the  strumous  and  rheumatic 
diatheses,  appear  to  be  predisposing  factors. 
McDonald  (  Diseases  of  the  Xose,  1890)  attributes 
the  majority  of  cases  to  obstruction  of  the  nasal 
fig.  3W.-RHINO8C0PIC  view  passages,  and  consequent  rarefaction  of  the  air 
of  veoetati  .xs  in  the  vault  in  the  naso-pharynx  during  respiration.  This 
of  the  pharynx  (Cohen).  theory,  however,  would  seem  to  be  opposed  to 
the  fact  that  nearly  all  cases  of  cleft  palate  are  also  affected  by  the  dis- 
ease; it  certainly  does  not  correspond  with  my  own  observations,  al- 
though it  is  true  that  in  many  cases  anterior  nasal  stenosis  does  exist. 

Symptomatology. — There  is  usually  a  history  of  mouth-breathing, 
which  has  lasted  for  several  months  or  years,  with  all  its  attendant 
svmptoms.  During  this  time  the  parents  have  been  continually  dis- 
turbed at  night  by  the  loud  snoring  of  the  patient.  The  child  is  usually 
very  restless,  and  often  wakens  from  troubled  dreams  during  the  early 
part  of  the  night,  but  later  sinks  into  a  heavy  sleep,  from  which  it 
wakens  in  the  morning  with  headache  or  a  feeling  of  malaise  that  does 
not  wear  off  for  several  hours.  Spasmodic  croup  is  sometimes  apparently 
caused  by  this  condition.  Xasal  or  post-nasal  catarrh  and  partial  deaf- 
ness are  not  infrequently  present,  and  it  is  common  to  find  that  these 
have  come  on  after  diphtheria  or  one  of  the  exanthematous  diseases. 
The  deafness  appears  to  be  due  to  obstruction  of  the  Eustachian  tube  by 
the  hypertrophied  gland,  and  in  some  cases  to  gradual  extension  of 
inflammation  to  the  middle  ear.  Acute  earaches  are  frequently  caused 
by  this  affection.  The  deafness  is  sometimes  outgrown  as  the  gland 
atrophies  during  advancing  life,  and  it  may  often  be  cured  by  removal 
of  the  abnormal  tissue,  but  if  allowed  to  persist  for  a  few  years  it  is  likely 
to  become  permanent. 

The  voice  is  thick  and  indistinct  in  proportion  to  the  interference 
with  nasal  resonance,  and  it  becomes  impossible  for  the  patient  to  sound 
the  letters  m  or  n,  especially  when  occurring  before  a  vowel,  I  and  d 
being  sounded  instead.  In  such  cases  the  voice  sounds  as  though  the 
patient  had  a  cold  in  the  head.  Wroblewski  of  Warsaw  {Internationale 
Klinische  Rundschau,  Vienna,  Annual  of  the  Universal  Medical  Sciences, 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL.  615 

1892)  found  adenoid  growths  in  over  fifty-seven  per  cent  of  one  hundred 
and  sixty  deaf  and  dumb  patients.  Shortness  of  breath  upon  exertion 
is  often  noticed,  and  where  children  are  trained  to  keep  the  mouth 
closed  we  may  frequently  observe  catching  or  sighing  respiration  at 
intervals,  an  effort  to  compensate  for  the  constant  deficiency  of  air ;  and 
it  is  often  necessary  for  these  patients  to  clear  out  the  mucus  from  the 
naso-pharynx  by  the  act  of  hawking.  A  barking,  reflex  cough  is  some- 
times present,  and  occasionally  a  spasmodic  affection  simulating  whoop- 
ing-cough. Often  a  peculiarly  disagreeable  nasal  screatus  becomes  a 
fixed  habit.  Occasionally,  though  not  in  the  majority  of  cases,  rhinor- 
rhcea  is  present. 

The  mucous  membrane  of  the  nostrils  and  anterior  nasal  cavi- 
ties is  found  abnormally  swollen  in  some  cases,  and  in  the  majority 
the  faucial  tonsils  are  also  enlarged.  The  uvula,  pillars  of  the  fauces, 
and  edge  of  the  palate  are  generally  slightly  congested,  and  frothy  or 
muco-purulent  secretion  is  found  upon  the  pharyngeal  wall  dropping 
down  from  the  naso-pharynx.  In  many  cases  the  pharynx  is  relaxed 
and  the  follicles  are  swollen,  as  in  advanced  cases  of  follicular  pharyn- 
gitis. The  follicles,  which  are  liable  to  be  paler  than  the  surrounding 
mucous  membrane,  usually  increase  in  size  toward  the  upper  part  of 
the  pharynx,  until  just  above  the  edge  of  the  palate  they  become  con- 
tinuous with  the  glandular  enlargement.  In  posterior  rhinoscopic  ex- 
amination we  should  observe  especially  the  posterior  pharyngeal  wall, 
the  vault  of  the  pharynx,  and  the  choanse.  Irregularity  of  the  upper 
outlines  of  the  latter  are  among  the  most  easily  recognized  signs  of  the 
disease. 

Upon  the  pharynx  the  growth  has  a  cushion-like  appearance,  more  or 
less  nodular  upon  its  surface,  but  in  rare  instances  it  hangs  from  the 
vault  in  soft,  pendulous  masses  resembling  condylomatous  warts.  In 
color  it  is  usually  pale  pink  or  grayish,  though  it  may  have  any  shade 
from  this  to  a  deep  red.  Its  surface  is  not  traversed  by  blood  vessels. 
In  adults,  where  atrophy  has  taken  place,  the  remains  of  the  gland  may 
sometimes  be  seen  as  small  excrescences.  Palpation  is  often  desirable  in 
adults  to  determine  the  consistency  of  the  growth,  and  it  is  frequently 
essential  in  children  because  of  the  difficulty  of  rhinoscopic  examination. 
In  performing  it,  a  gag  having  been  placed  between  the  teeth,  the  fore- 
finger of  the  right  hand  should  be  carried  back  to  the  pharyngeal  wall 
and  then  turned  upward  behind  the  palate,  where  it  at  once  detects  the 
abnormal  growth.  Those  unfamiliar  with  the  normal  feeling  of  the  part 
should  at  first  search  for  the  septum  and  carry  the  examination  from  this 
backward  and  upward  along  both  sides.  Slight  bleeding  usually  follows, 
though  the  examination  is  not  specially  painful  to  the  patient.  Chronic 
pharyngitis,  rhinitis,  or  laryngitis  will  be  found  present  in  some  cases, 
and  occasionally  deformity  of  the  thorax  will  have  resulted,  as  shown  in 
the  pyriform  chest  or  pigeon-breast  already  referred  to  in  speaking  of 
hypertrophy  of  the  tonsils. 


616  *         DISEASES   OF  THE  NASO-PHARYNX. 

Diagnosis. — The  affection  is  to  be  distinguished  from  nasal  mucous 
polypi  and  fibroid  tumors  by  inspection  and  palpation. 

We  seldom  find  mucous  polypi  at  so  early  an  age  as  hypertrophy  of 
the  pharyngeal  tonsil;  they  are  of  a  lighter  color,  semi-translucent, 
and  usually  have  coursing  across  their  surface  blood  vessels,  which  are 
not  seen  in  this  disease.  They  usually  spring  from  the  nasal  cavities 
and  may  be  readily  detected  by  anterior  rhinoscopy. 

We  find  fibroid  tumors  much  harder  than  the  hypertrophied  glandular 
tissue;  they  are  frequently  attended  by  severe  epistaxis,  and,  upon  being 
touched,  bleed  easily  and  profusely.  They  are  usually  of  a  bright  red 
color  with  blood  vessels  apparent  upon  the  surface.  When  large,  they 
cause  distortion  of  the  neighboring  parts.  None  of  these  signs  are  ob- 
served in  hypertrophy  of  the  pharyngeal  tonsil. 

Prognosis. — Probably  in  seventy-five  per  cent  of  the  cases  the 
gland,  if  left  to  itself,  would  atrophy  at  about  the  twelfth  or  fourteenth 
year  of  the  patient's  age;  but  in  the  mean  time  irreparable  mischief 
to  the  ear,  the  voice,  or  the  general  health  may  result.  In  the  re- 
maining cases  the  gland  gradually  diminishes  in  size,  and  disappears 
before  middle  life.  When  the  affection  has  existed  for  a  long  time,  the 
hearing  may  be  permanently  impaired,  but  usually  removal  of  the  gland 
greatly  benefits  this  condition.  The  voice  is  not  always  perfectly  re- 
stored, because  a  person  having  learned  to  talk  with  an  obstruction  in 
the  naso-pharynx  may  require  a  considerable  time  to  overcome  the  mus- 
cular habit,  and  in  adults  it  may  never  be  entirely  remedied.  The 
results  of  operative  procedure,  if  not  too  long  delayed,  are  most  satis- 
factory. 

Treatment. — Internally,  particularly  for  anaemic  children,  I  have 
occasionally  found  the  syrup  of  iodide  of  iron  of  value.  Sometimes 
other  preparations  of  the  iodides  will  prove  beneficial  and  probably 
calcium  chloride  might  cause  some  reduction  of  the  gland  in  some  in- 
stances. As  a  rule,  however,  medicinal  treatment  is  of  little  value. 
Locally,  astringents  have  been  recommended,  and  seem  to  be  useful  in  a 
few  cases. 

The  most  satisfactory  results  follow  removal  of  the  gland  by  surgical 
measures,  and  there  are  no  contra-indications  to  operating  even  on  young 
children.  In  a  few  patients  where  friends  have  objected  to  an  operation 
I  have  employed  chromic  acid  successfully.  In  using  this  caustic  I  fuse 
a  few  crystals  on  the  end  of  a  flat  aluminium  probe  and  pass  this  through 
the  nostril  to  the  enlarged  pharyngeal  tonsil,  where  it  is  held  for  two  or 
three  seconds.  Previously  the  nares  may  be  oiled  to  prevent  the  possible 
contact  of  any  of  the  acid  with  its  mucous  membrane,  and  a  small  amount 
of  cocaine  may  have  been  applied  to  the  nares  and  naso-pharynx  by 
means  of  powder  or  spray.  The  acid  applied  in  this  way  usually  causes 
a  moderate  amount  of  pain  at  the  time,  and  some  soreness  for  several 
hours  afterward,  but  it  is  not  severe.     The  applications  may  be  repeated 


HYPERTROPHY  OF  THE  PHARYNGEAL   TONSIL.  617 

once  in  from  three  to  five  days,  being  made  through  the  opposite  nostrils 
alternately. 

The  galvano-cautery  may  be  used  to  destroy  the  growth,  a  bent 
electrode  being  passed  up  behind  the  palate,  but  the  method  is  painful, 
tedious,  and  altogether  not  very  satisfactory.  Scraping  off  the  gland  by 
means  of  a  long  finger-nail  or  various  forms  of  curettes  is  in  favor  with 
some  operators  and  may  in  certain  cases  answer  an  excellent  purpose; 
but  usually  the  operation  is  less  complete  than  when  performed  by 
Loewenberg's  forceps,  and  therefore  recurrence  is  more  likely  to  take 
place.  Ecrasement  by  means  of  a  bent  snare  is  practised  satisfactorily 
in  some  cases  where  the  growth  is  very  soft.  Some  operators  prefer 
scissors  or  punch-like  forceps,  but  they  are  both  open  to  some  objections. 
The  scissors -like  instruments  which  I  have  seen  may  be  satisfactory 
for  cutting  out  a  portion  of  the  mass,  when  it  is  soft,  but  they  are 
not  well  adapted  to  a  complete  extirpation  of  the  growth,  so  that  other 
instruments  must  generally  be  used  to  make  a  complete  operation. 
The  punch-like  forceps  are  not  open  to  the  same  objection,  but  it  is 
asserted  that  unnecessary  bleeding  results  from  their  use. 

By  far  the  most  satisfactory  instrument  to  me  for  extirpation  of  the 
gland  is  Loewenberg's  forceps,  or  some  one  of  its  modifications,  espe- 
cially that  suggested  by. John  N.  Mackenzie.  I  have  had  a  similar  in- 
strument made  with  shorter  blades,  for  operating  upon  young  children. 

In  performing  the  operation  upon  adults,  it  is  often  sufficient  to  an- 
aesthetize the  parts  by  cocaine,  which  may  be  applied  by  spray,  syringe, 
or  swab,  or  by  the  hypodermic  syringe  with  a  bent  needle,  by  which  it 
may  be  injected  directly  into  the  gland.  My  own  custom  has  been  to 
apply  a  ten  per  cent  solution  by  spray  behind  the  palate,  and  a  similar 
solution  by  means  of  a  syringe  with  a  long  blunt  nozzle,  to  the  upper 
part  of  the  gland  through  the  nares.  The  application  should  be  re- 
peated about  once  a  minute  until  the  part  is  fairly  anaesthetized,  which 


Fig.  235. — Mackenzie's  Modification  of  Loewenberg's  Forceps. 

will  take  about  ten  minutes.  A  self-retaining  palate  retractor  should 
then  be  adjusted  and  the  patient  may  hold  the  tongue  with  a  depressor. 
The  forceps  are  then  inserted  with  the  aid  of  the  rhinoscopic  mirror, 
and  thus  one  or  two  bites  may  be  made  accurately,  but  subsequently  the 
blood  obstructs  the  view  and  the  remainder  of  the  operation  may  be 
postponed  to  another  sitting  or  completed  by  the  sense  of  touch  if  the 
patient  will  permit.     Usually,  even  with  cocaine,  after  two  or  three 


618  DISEASES   OF  THE  NA80-PHARYNJT. 

bites  have  been  made,  patients  prefer  to  have  the  remainder  of  the  op- 
eration done  at  another  time.  Two  or  three  sittings,  however,  will  be 
sufficient  in  the  majority  of  these  eases.  When  an  anaesthetic  is  objected 
to,  or  if  for  any  reason  a  complete  operation  will  not  be  permitted,  a 
single,  large  excision  may  be  recommended  when  the  gland  is  soft. 
This,  in  the  case  of  either  children  or  adults,  will  generally  give  much 
relief.  In  children  chloroform  or  ether  should  lie  administered,  chloro- 
form being  preferable.  When  anaesthesia  is  complete,  the  child  should 
be  turned  upon  its  abdomen  and  face,  the  month  coming  over  the  side 
of  the  table.     A  gag  should  then  be  inserted  to  hold  the  teeth  apart. 

Henrotin's  gag  is  the  simplest  one  that  I  have  seen  for  this  purpose,  but 
sometimes  Alliugham's  will  be  fouud  preferable,  especiallj'  for  large  children 
(Fig.  113). 

The  surgeon  standing  at  the  right  side  of  the  table,  facing  the 
patient's  head,  passes  the  index  linger  of  his  left  hand  behind  the  palate 
into  the  naso-pharynx,  where  it  is  retained  as  a  guide  for  the  forceps. 
The  forceps  may  then  be  passed  along  the  dorsal  aspect  of  the  finger 
and  applied  accurately  to  the  growth.  Thus  piece  by  piece  the  gland 
is  extracted,  the  forceps  being  guided  each  time  by  the  finger  until 
every  part  has  been  extirpated.  Care  should  be  taken  to  avoid  seizing 
the  posterior  edge  of  the  vomer  or  the  projecting  end  of  the  Eusta- 
chian tubes.  The  latter  often  feel  to  the  uneducated  finger  like  ab- 
normal growths.  If  care  is  taken  not  to  turn  the  forceps  sideways, 
there  is  but  little  danger  of  doing  damage,  providing  the  operator  is 
familiar  with  the  normal  condition  of  the  parts.  Sometimes  masses, 
located  just  back  of  the  Eustachian  orifice,  are  liable  to  be  overlooked, 
but  the  most  common  difficulty  arises  from  small  pendent  masses 
which  hang  just  back  of  the  choanee  aud  are  liable  to  be  crowded  for- 
ward by  the  finger  into  the  posterior  nares.  It  is  sometimes  quite  diffi- 
cult to  get  the  finger  in  front  of  this  mass  and  push  it  back  where  it 
may  be  caught  with  the  forceps.  Some  operators  attempt  to  scrape  this 
portion  of  the  growth  away  with  the  finger-nail,  but  this  effort  can  only 
be  partially  successful.  When  I  find  difficulty  in  removing  this  part  with 
the  post-nasal  forceps,  I  employ  a  straight  nasal  forceps  with  cutting 
edge  (Fig.  229),  which  I  pass  through  the  nostril,  and  guide  to  the  proper 
point  in  the  vault  of  the  pharynx  with  my  finger  still  retained  behind 
the  palate.  In  this  manner  a  piece  which  might  otherwise  be  difficult 
to  catch  is  very  readily  removed.  This  procedure  also  enables  us  to 
determine  whether  the  nasal  fossa?  are  free,  or  if  they  are  not  to  break 
down  any  adhesions  or  slight  bony  obstruction.  With  the  patient  in  the 
position  just  recommended,  there  is  no  necessity  for  care  in  swabbing 
out  the  throat,  as  the  blood  cannot  run  up  the  trachea.  With  the 
patient  on  his  back  ami  the  head  thrown  far  backward,  as  recommended 
by  some  English  surgeons,  it  is  necessary  to  swab  out  the  throat  and 


HYPERTROPHY  OF  THE  PHARYNGEAL   TONSIL.  619 

naso-pharynx  frequently  to  prevent  blood  from  getting  into  the  air  pas- 
sages. There  is  usually  considerable  bleeding,  but  this  stops  as  soon  as 
the  operation  is  completed.  If  undue  hemorrhage  should  occur,  the 
vault  of  the  pharynx  may  be  packed  in  the  usual  way  or,  as  I  prefer, 
with  a  long  strip  of  gauze  which  is  passed  through  the  nares.  This  strip 
is  saturated  with  a  thick  solution  of  tannic  and  gallic  acids,  as  recom- 
mended for  checking  hemorrhage  from  the  nares.  This  should  be 
pushed  back  through  the  nares,  and  packed  up  behind  the  palate  with 
the  finger,  which  is  inserted  through  the  mouth.  The  nares  should  also 
be  packed,  and  the  gauze  brought  forward  to  the  nostril  to  prevent  the 
packing  from  falling  into  the  throat.  This  packing  should  be  removed 
within  from  twelve  to  twenty-four  hours,  to  avoid  the  danger  of  exciting 
inflammation  of  the  middle  ear. 

When  the  operation  is  completed,  the  mouth  should  be  wiped  out  and 
the  nostrils  squeezed  to  press  out  what  blood  is  possible,  but  it  is  neither 
necessary  nor  desirable  to  wash  out  the  parts.  The  patient  should  then  be 
placed  in  bed,  and  it  is  well  for  the  nurse  to  keep  him  as  much  as  possible 
upon  the  face  till  he  has  thoroughly  recovered  from  the  chloroform. 
This  latter  suggestion,  however,  is  not  very  important,  and  it  is  seldom 
followed.  The  patient  should  be  kept  in  bed  for  a  few  hours,  and  in 
the  house  for  from  two  days  to  a  week  according  to  the  weather. 
During  this  time  I  usually  have  insufflations  made  through  the  nostrils 
two  or  three  times  during  the  day,  of  a  powder  of  two  per  cent  of 
cocaine,  fifty  per  cent  of  iodol,  and  sufficient  sugar  of  milk  to  make  one 
hundred  parts.  A  simple  detergent  alkaline  spray  is  not  objectionable, 
but  washes  should  be  avoided  for  fear  of  injury  to  the  middle  ear;  even 
sprays  will  sometimes  find  their  way  up  the  Eustachian  tube,  and  there- 
fore, unless  by  the  odor  there  seems  to  be  a  special  indication  for  them, 
I  prefer  to  use  the  powder  in  connection  with  an  antiseptic  oily  spray 
containing  thymol  gr.  -|-,  oleum  caryophylli  TTliij.,  toliquid  albolene   3  i. 

As  a  result  of  the  operation  there  is  usually  a  little  soreness  of  the 
parts  for  a  day  or  two,  but  not  sufficient  to  interfere  with  swal- 
lowing. There  is  sometimes  slight  elevation  of  temperature;  the  im- 
provement in  breathing  is  marked  and  immediate  in  many  cases; 
very  often  the  friends  become  alarmed  during  the  first  night  because 
the  child  breathes  so  quietly.  Where  partial  deafness  exists,  consider- 
able improvement  may  be  expected  within  a  few  days  or  weeks,  but 
recovery  from  alterations  of  the  voice  is  sometimes  less  rapid.  Some 
danger  of  otitis  media  exists  from  the  liability  of  blood  or  other  fluids 
passing  into  the  Eustachian  tube,  but  thus  far  no  permanently  bad 
results  have  been  observed  from  it.  In  case  it  should  occur,  the  con- 
tinuous use  of  hot  water  in  the  ear,  or  hot  water  with  glycerin  and 
opium  and  dry  heat  externally,  are  the  best  remedies  that  can  be 
employed. 

In  some  cases  nasal  obstruction  will  be  found  to  exist  after  the  opera- 


620  DISEASED   OF  THE  N4S0-PHABTNX. 

tion,  and  it  must  receive  appropriate  treatment  subsequently.  The  final 
results  of  removing  the  hypertrophied  pharyngeal  tonsil  are  the  most 
satisfactory  of  any  with  which  I  am  acquainted  in  the  domain  of  special 
surgery.  The  operation  should  not  be  recommended  unless  the  dis- 
eased gland  is  large  enough  to  interfere  with  nasal  respiration,  at  least 
when  the  patient  has  a  cold,  or  unless  it  affects  the  sense  of  hearing  by 
pressure  on  the  orifice  of  the  Eustachian  tube.  In  cases  suitable  for 
the  operation,  the  patient's  general  condition  undergoes  a  revolution 
for  the  better,  which  often  astonishes  even  the  physician,  and  gives  the 
friends  most  unbounded  satisfaction.  In  a  child  of  from  three  to  six 
years  of  age  it  is  not  unusual  for  a  gain  in  weight  of  from  twenty  to 
twenty-five  per  cent  to  occur  within  five  or  six  months  after  the  gland 
has  been  removed.  I  have  never  seen  any  ill  results  follow  the  opera- 
tion, and  I  think  it  safe  to  tell  the  friends  that  when  properly  done  it  is 
no  more  dangerous  than  the  removal  of  a  finger. 

RETRO  NASAL  FIBROUS  TUMORS. 

Fibrous  tumors  of  the  naso-pharynx  are  characterized  by  obstruc- 
tion of  the  nose  and  dyspnoea,  frequent  epistaxis,  and,  when  large,  by 
great  disfigurement  known  as  frog  face.  They  usually  occur  in 
young  adults,  sometimes  in  infants,  but  seldom  after  the  twenty-fifth 
year  of  age,  and  they  are  much  more  common  in  men  than  in  women. 
The  affection  is  so  rare  that  in  over  five  thousand  records  of  private 
patients  suffering  from  disease  of  the  throat  and  nose  Tfind  but  six  cases. 

AXATOMICAL    AND    PATHOLOGICAL  CHARACTERISTICS. — The  growths 

are  generally  smooth,  hard,  and  unyielding,  red  or  purplish  in  color, 
and  sometimes  ulcerated  or  bathed  in  a  sanious  secretion.  They  may 
spring  from  the  periosteum  of  any  portion  of  the  roof  or  lateral  walls 
of  the  naso-pharyngeal  cavity,  but  they  usually  originate  from  the  basilar 
process  of  the  occipital  bone  and  the  body  of  the  sphenoid,  or  from 
the  upper  cervical  vertebrae.  In  character  they  are  like  fibromata  in 
other  localities,  but  occasionally  are  composed  quite  largely  of  erectile 
tissue.  They  are  exceedingly  dense,  destitute  of  elastic  fibres,  and  the 
blood  vessels  in  their  interior  are  small,  while  those  in  the  investing 
membrane  are  larger,  and  have  brittle  walls  which  render  them  pecul- 
iarly liable  to  bleed.  The  tumor  is  usually  single  and  attached  by  a 
broad  pedicle. 

Etiology. — The  etiology  is  unknown. 

Symptomatolqgy. — The  patient  first  experiences  a  sense  of  obstruc- 
tion in  the  naso-pharynx,  and  finally  one  or  both  nasal  passages  become 
occluded.  Many  complain  much  of  fatigue  and  drowsiness,  probably  due 
to  imperfect  aeration  of  the  blood.  Later,  the  symptoms  depend  upon 
the  direction  which  the  tumor  may  take  in  its  development.  If  it 
extends  toward  the  throat,  it  interferes  with  deglutition ;    by  pressure 


RETRO-NASAL  FIBROUS  TUMORS.  621 

upon  the  Eustachian  tube,  it  may  excite  inflammation  of  the  middle  ear, 
with  more  or  less  pain  and  deafness.  When  it  projects  forward,  the 
nasal  bones  may  be  separated,  the  eyes  pushed  apart,  and  the  bridge  of 
the  nose  flattened,  giving  the  characteristic  deformity  already  mentioned 
as  frog  face.  Pressure  upon  the  lachrymal  ducts  causes  epiphora. 
Sometimes  the  tumor  extends  into  the  antrum  of  Highmore  and  gives 
rise  to  swelling  of  the  cheek.  It  may  perforate  and  fill  the  sphenoid 
cells,  and  sometimes,  as  in  one  instance  I  have  seen,  it  may  cause 
absorption  of  the  base  of  the  skull,  pressure  upon  the  brain,  and  fatal 
meningitis.  The  filling  up  of  the  naso-pharynx  interferes  with  articu- 
lation, giving  a  nasal  twang  to  the  voice,  and,  if  the  tumor  is  large  and 
extends  downward,  great  dyspnoea  may  occur.  There  is  usually  profuse 
purulent  or  muco-purulent  secretion,  sometimes  offensive  in  character; 
and  epistaxis,  frequent  and  sometimes  dangerous,  is  a  common  symptom. 
Dysphagia  may  be  present.  By  inspection  of  the  anterior  and  posterior 
nares,  and  palpation  with  the  finger,  the  characteristics  already  pointed 
out  may  be  readily  detected. 

Diagnosis. — The  growths  are  liable  to  be  mistaken  for  mucous  or 
fibroy-mucous  polypi  and  sarcomata.  From  the  latter  they  can  only  be 
distinguished  by  a  microscopic  examination.  The  essential  points  in 
the  diagnosis  are  the  age,  sex,  smoothness  and  density  of  the  growth, 
and  frequent  epistaxis.  They  are  distinguished  from  mucous  polypi  by 
their  color,  density,  and  tendency  to  bleed.  Fibromata  are  distinguished 
from  fihro-mucous  polypi  or  tumors,  the  latter  being  less  dense,  having 
less  tendency  to  bleed,  und  by  microscopic  examination.  We  might  pos- 
sibly mistake  hypertrophy  of  Lusclilca'1  s  tonsil  for  fibromata,  from  which 
it  will  be  differentiated  by  the  age  of  the  patient,  its  slower  growth, 
lack  of  tendency  to  bleed,  and  by  its  having  a  lighter  color,  more  irreg- 
ular surface,  and  less  density.  Adenoid  vegetations  in  the  vault  of  the 
pharynx  bleed  easily,  are  soft,  irregular,  and  occur  at  an  earlier  age  than 
fibrous  tumors. 

Prognosis. — The  growths  tend  steadily  to  increase  in  size,  and, 
unless  recognized  and  removed,  will  prove  fatal  in  most  cases,  in  the 
course  of  four  or  five  years.  Even  when  removed,  there  yet  remains  a 
strong  tendency  to  recurrence,  but  fortunately,  if  they  can  be  kept  in 
check  until  the  patient  has  attained  the  age  of  twenty-five,  there  is  a 
tendency  to  sjDontaneous  arrest  of  development. 

Treatment. — If  possible,  the  tumor  should  be  removed  through  the 
natural  passages  by  the  ecraseur,  galvano-cautery,  or  by  electrolysis. 
When  large,  it  may  be  necessary  to  adopt  the  more  severe  measures 
recommended  by  Dupuytren,  Eouge,  Eangenbeck,  Chassaignac,  Oilier, 
Lawrence,  Palasciano,  or  Eampolla,  which  consist  of  various  operations 
for  exposure  and  removal  of  the  tumor  through  the  face  that  are  fully 
described  in  the  textbooks  on  surgery.  I  have  never  seen  cases  in 
which  these   methods  were  necessary,  and  the   experience   of  Lincoln 


622  DISEASES  OF  THE  NASOPHARYNX. 

(Transactions  of  the  American  Laryngological  Association,  1883),  as 
well  as  my  own  experience  in  two  cases,  show  that  even  large  tumors 
may  be  extirpated  through  the  nares  and  naso-pharynx  with  even 
better  results  than  are  obtained  by  external  operations.  The  sim- 
plest operation,  and  one  which  is  sometimes  attended  by  success,  consists 
of  electrolysis,  which  is  performed  by  passing  one  or  more  needles 
connected  with  the  negative  pole  into  the  tumor  from  behind  the 
palate  or  through  the  nares,  a  single  needle  connected  with  the  positive 
pole  being  introduced  in  a  similar  manner.  A  continuous  current  as 
strong  as  the  patient  can  tolerate  should  be  used,  and  the  operation 
continued  ten  or  fifteen  minutes,  and  repeated  about  once  a  week  or 
less  frequently  according  to  circumstances,  until  the  growth  has  been 
dissipated. 

Ligatures  have  been  employed  for  the  removal  of  these  growths,  but 
they  are  less  satisfactory  than  the  ecraseur  or  galvano-cautery.  In  all 
cases  when  ligation  is  practised,  a  thread  should  be  passed  through  the 
neoplasm  and  brought  out  at  the  mouth  so  that  upon  separation  the 
mass  may  be  removed  before  it  falls  deep  into  the  throat  and  causes 
strangulation.  « 

When  a  strong  ecraseur  of  sufficient  power  can  be  passed  about  the 
tumor,  it  may  be  readily  and  safely  removed  by  this  instrument,  but  the 
chances  of  recurrence  are  greater  than  if  the  galvano-cautery  snare  is 
used.  Evulsion  by  strong  forceps  has  been  practised  in  some  cases,  but 
this  method  is  not  generally  applicable.  The  tumor  may  be  cut 
away  with  a  curved,  blunt-pointed  bistoury,  curved  scissors,  or  strong 
cutting-forceps;  or  it  may  be  removed  by  the  gouge.  Any  of  these 
methods  are  applicable  in  some  instances,  but  they  are  apt  to  be  at- 
tended by  profuse  hemorrhage,  and  if  much  force  is  used  the  resulting 
inflammation  may  prove  fatal  by  extension  to  the  brain,  as  in  two  of 
Ollier's  cases  (Spillmann:  Dictioimaire  Encyclopedic  des  Sciences  medi- 
cates, fig.,  seconde  serie,  Tome  XIII). 

When  the  tumor  is  jDedunculated,  it  may  sometimes  be  secured  in 
the  loop  of  an  ecraseur,  but  more  easily  in  a  loop  of  steel  wire  used 
with  the  ordinary  snare;  usually  the  tissue  is  so  firm  that  it  cannot  be 
cut  with  the  cold-wire  snare  in  common  use.  The  Xo.  5  piano  wire 
used  for  mucous  polypi  is  liable  to  break,  and  wire  of  larger  size  cuts 
the  tissue  much  less  easily,  so  that  it  cannot  be  drawn  through  the 
pedicle  excepting  with  a  stronger  and  much  more  powerful  instrument. 
The  galvano-cautery  snare  (Fig.  207)  is  the  best  instrument  for  the 
removal  of  these  tumors  whenever  they  are  sufficiently  pedun- 
culated to  allow  of  its  employment.  In  performing  the  operation,  I 
pass  two  soft  catheters  through  the  naris,  endeavoring  to  carry  one  on 
either  side  of  the  growth,  and  bring  them  out  of  the  mouth.  Into  the 
ends  that  are  brought  out  of  the  mouth  the  ends  of  a  piece  of  platinum 
wire  about  three  feet  in  length  are  introduced  and  pushed  on  until  they 


RETRO-NASAL  FIBROUS  TUMORS.  623 

come  out  of  the  nostril.  I  attach  a  thread  to  the  wire  loop  to  enable 
me  to  draw  it  backward  in  case  of  failure  on  the  first  attempt  to  place 
it  about  the  tumor.  The  catheters  with  the  wires  protruding  from  the 
nostril  are  now  drawn  upon  and  the  loop,  passing  back  into  the  mouth, 
is  carried  with  the  finger  or  with  the  aid  of  a  post-nasal  snare-appli- 
cator (Fig.  236)  up  about  the  tumor,  where  it  is  drawn  firmly  into 
place.  The  catheters  are  then  withdrawn,  and  the  wires  intrusted  to  an 
assistant,  who  holds  them  carefully,  to  prevent  their  becoming  crossed 
in  the  naris.  The  ends  of  the  wire  are  then  slipped  through  the  tubes 
of  the  galvano-cautery  ecraseur  and  fastened  to  the  ratchet  on  the  handle. 
It  is  desirable  to  have  the  distal  ends  of  this  electrode  separated  about 
a  quarter  of  an  inch  or  even  more,  so  that  it  may  be  the  more  readily 
passed  upon  either  side  of  the  tumor.  As  the  instrument  is  pushed 
into  the  nose,  the  ratchet  is  turned  to  tighten  the  loop,  which  is  drawn 


Fig.  236.— Ingals'  Post-Nasal  Snare  Applicator  Q4  size) .  For  tumors  in  naso-pharynx.  The 
wire  loop  is  held  in  notches  at  D  by  the  slides  B,  C,  which  are  held  firmly  by  the  cam  A.  As  the  loop 
is  carried  behind  the  palate,  the  blades  are  opened  so  that  the  wire  incloses  the  tumor ;  it  is  then 
tightened,  the  cam  is  loosened,  the  slides  B,  C  are  drawn  slightly  backward,  and  the  wire  is  re- 
leased and  left  in  position  while  the  applicator  is  withdrawn. 

tight  upon  the  pedicle  of  the  tumor  before  the  electric  current  is  turned 
on. 

As  it  is  very  difficult  to  adjust  the  platinum  loop  properly  with 
the  patient  under  ether  or  chloroform,  I  have  in  recent  cases  relied 
upon  the  anaesthetic  effects  of  cocaine  ;  but  its  benumbing  effect  in 
this  locality  is  not  sufficient  to  prevent  considerable  pain  during  the 
burning  off  of  the  growth;  therefore,  when  everything  is  in  readiness, 
I  tell  the  patient  to  bear  the  burning  as  long  as  possible,  and  that  I 
will  stop  the  current  as  soon  as  he  requests  it.  The  current  is  then 
turned  on  and  the  ratchet  tightened  at  the  same  time.  The  patient 
will  endure  the  pain  two  or  three  seconds,  then  the  circuit  is  broken 
and  he  is  allowed  to  wait  two  or  three  minutes;  as  soon  as  he  is  again 
ready,  the  circuit  is  again  closed  and  thus  the  process  is  continued  until 
the  pedicle  is  burned  through.  The  tumor  is  then  seized  with  a  pair 
of  post-nasal  forceps  and  withdrawn  through  the  mouth.  There  is 
little  or  no  hemorrhage  from  this  operation. 

Whenever  as  the  result  of  an  operation  hemorrhage  ensues,  it  may 
be  necessary  to    plug   the   posterior   nares.     For  this  purpose  I   have 


624  DlsEAs£s   OF  THE  NASO-PHARYNX. 

found  most  satisfaction  in  passing  through  the  naris  a  long  strip  of 
gauze,  rendered  styptic  by  saturation  with  tannic  and  gallic  acid-,  us 
..mended  in  the  treatment  of  epistaxis.  The  gauze  is  pushed  hack 
with  the  probe  through  the  naris  to  the  naso-pharynx,  and  there  it  is 
packed  into  the  vault,  with  the  finger  carried  up  behind  the  palate. 
Finally,  the  naris  itself  is  completely  filled  to  prevent  the  plug  from  fall- 
ing into  the  throat  if  it  should  become  loosened.  The  tampon  should 
be  removed  within  from  twelve  to  twenty-lour  hours,  by  traction  upon 
the  end  protruding  from  the  nostril,  by  which  the  strip  is  gradually 
unfolded.  In  case  clotting  of  blood  has  rendered  the  tampon  hard,  and 
bound  its  folds  together,  it  should  be  softened  by  gently  injecting  into 
the  nostril  a  warm  solution  of  sodium  bicarbonate.  Should  recurrence 
of  the  tumor  take  place,  it  should  be  treated  while  it  is  yet  small  by  the 
galvano-cautery  or  by  electrolysis. 

RETRONASAL  FIBRO-MUCOUS  TUMORS. 

Retro-nasal  fibro-mucous  polypi  are  smooth,  more  or  less  ovoid 
tumors,  varying  from  two  to  ten  centimetres  in  diameter.  They  cause 
obstruction  of  the  posterior  nares,  especially  in  expiration,  with  conse- 
quent inability  to  blow  the  nose.  They  are  less  frequent  than  the 
fibrous  tumors. 

Anatomical  and  Pathological  Characteristics. — The  growths 
originate  near  the  posterior  opening  of  the  nasal  fossa?  and  are  more  or 
less   fibrous  or  mucous   according  to  their   position.     Those   growing 


Fir.  VST.  — Retro-Nasal  Fibro-Mucous  Tcmor. 

largely  from  the  retro- nasal  space  are  mostly  fibrous,  those  from  the 
nares,  as  a  rule,  are  chiefly  mucous,  in  character.  They  do  not  cause  so 
much  pressure  as  fibrous  tumors,  and  do  not  displace  the  bony  structures 
like  the  latter. 

Etiology. — The  etiology  is  unknown. 

Symptomatology. — The  growths  develop  slowly,  and  are  attended 
by  the  well  known  symptoms  of  nasal  obstruction. 

Diagnosis. — The  retro-nasal  fibro-mucous  polypi  are  to  be  distin- 
guished from  fibrous  and  mucous  polypi  and  malignant  growths.  They 
differ  from  fibrous  tumors  in  that  They  are  less  dense,  they  do  not  de- 


MALIGNANT  TUMORS  OF  THE  NASO-PHARYNX.  625 

stroy  the  bony  structures,  and  they  are  not  attended  by  frequent  epi- 
staxis.  They  are  distinguished  from  mivcous  polypi  by  their  greater 
density,  their  darker  color,  and  by  their  size  and  position.  They  are 
distinguished  from  malignant  growths  by  the  history,  absence  of  pain 
and  hemorrhage,  smooth  surface,  and  less  degree  of  density. 

Prognosis. — The  tumors  grow  slowly,  and  when  removed  have  lit- 
tle tendency  to  recur. 

Treatment. — If  not  too  firm,  the  tumors  may  be  safely  torn  away 
with  post-nasal  forceps,  but  they  are  best  removed  with  the  steel  wire 
ecraseur  or  galvano-cautery  applied  as  recommended  in  speaking  of 
fibromata. 

RETRO-NASAL  CARTILAGINOUS   TUMORS. 

True  cartilaginous  tumors  of  the  retro-nasal  locality  are  so  rare  as 
to  barely  need  mention.     Only  three  or  four  cases  are  on  record. 

MALIGNANT  TUMORS  OP  THE  NASO-PHARYNX. 

Malignant  tumors  of  the  naso-pharynx  are  comparatively  rare  ;  they 
are  characterized  by  symptoms  of  nasal  obstruction,  with  abundant  dis- 
charge, frequent  epistaxis,  and  often  by  severe  pain. 

Anatomical  and  Pathological  Characteristics. — The  growths 
are  usually  more  or  less  pedunculated,  somewhat  pyriform  in  shape, 
and  they  have  a  nodular  or  lobulated  surface  covered  by  mucous 
membrane.  They  appear  to  be  mostly  of  a  sarcomatous  nature,  and 
often  contain  mucous  or  fibrous  % elements  to  a  considerable  extent. 
Microscopically  they  are  found  to  contain  the  usual  round  or  spindle- 
shaped  cells  and  sometimes  cartilaginous  cells.  In  common  with  malig- 
nant tumors  elsewhere,  they  are  characterized  by  rapid  growth,  speedy 
recurrence  after  removal,  and  tendency  to  form  new  deposits  in  other 
organs. 

Etiology. — The  etiology  is  unknown. 

Symptomatology. — The  tumors  cause  the  common  symptoms  of 
nasal  obstruction,  with  more  or  less"  discharge  and  bleeding,  and  often, 
but  not  invariably,  severe  lancinating  pain  shooting  toward  the  ear  and 
most  troublesome  at  night.  As  the  tumor  increases  in  size,  dyspnoea 
and  dysphagia  may  become  j)ronounced.  It  may  be  readily  seen  upon 
rhinoscopic  inspection. 

Diagnosis. — The  malignant  tumor  is  to  be  distinguished  from  other 
retro-nasal  growths  by  the  features  mentioned  in  speaking  of  fibrous 
and  fibro-mucous  polypi,  and  by  microscopic  examination. 

Prognosis. — The  tumors  grow  rapidly  and  terminate  fatally,  usually 
within  from  four  to  six  months.     Eecurrence  is  the  almost  constant  rule. 

Treatment. — When  seen  in  the  early  stage,  if  possible,  the  growths 
should  be   thoroughly  removed  by  the  steel  wire  or  galvano-cautery 
snare;  but  more  serious  operations  cannot  be  advised. 
40 


626  DISEASES   OF  THE  NASOPHARYNX. 

CYSTIC  TUMORS   OF  THE  NASOPHARYNX. 

Cystic  tumors  of  the  naso-pharynx  are  of  rare  formation;  only  a  few 
cases  have  been  reported  in  this  country,  by  Lefferts,  Clinton  Wagner, 
and  myself.  They  are  characterized  by  the  usual  signs  and  symptoms 
of  nasal  obstruction.  They  are  most  readily  removed  by  evulsion 
with  strong  post-nasal  forceps,  and  show  little  or  no  tendency  to  recur- 
rence. 


Diseases  of  the  Thyroid  Gland 
and  cesophagus. 


CHAPTER  XXXVII. 

DISEASES   OF   THE   THYROID   GLAND. 

GOITRE. 

Synonyms. — Bronchocele,  Derbyshire  neck,  struma. 

Goitre  consists  of  an  enlargement  of  the  thyroid  gland,  which  may 
be  vascular,  parenchymatous,  or  cystic. 

Anatomical  and  Pathological  Characteristics. — In  the  vas- 
cular  variety  in  some  cases  the  veins,  in  others  the  arteries,  and  in  still 
others  all  the  blood  vessels  are  enlarged,  elongated,  and  tortuous,  and 
the  walls  may  be  greatly  thickened,  so  that  the  vessels  themselves  make 
up  a  large  part  of  the  increased  size  of  the  gland.  In  the  parenchym- 
atous variety  the  glandular  structure  itself  is  increased,  sometimes  the 
alveoli  are  much  enlarged,  and  the  tumor  is  made  up  in  great  part  of 
colloid  material,  while  in  other  cases  the  alveoli  are  smaller  and  the 
tumor  is  composed  largely  of  the  solid  stroma.  In  many  instances 
the  goitre  consists  mainly  of  true  adenoid  growth.  In  cystic  goitre 
there  may  be  one  or  more  large  or  small  cysts,  usually  combined  with 
hypertrophy  of  the  parenchyma  to  a  greater  or  less  extent.  As  a  rule, 
these  cysts  contain  tenacious,  ropy,  albuminous  fluid,  often  more  or  less 
tinged  with  blood  from  rupture  of  varicose  veins  into  them,  and  of 
various  shades  of  color  in  consequence  of  the  amount  or  condition  of 
the  blood  which  has  been  thrown  out.  Sometimes  their  contents  are 
entirely  serous  and  in  other  cases  entirely  hemorrhagic  in  character. 
These  growths  sometimes  attain  enormous  size.  They  are  more  frequent 
in  women  than  in  men,  and  are  most  apt  to  occur  at  about  the  age  of 
puberty.  The  disease  is  most  common  in  the  Italian  and  Swiss  Alps, 
the  Pyrenees  in  France,  in  the  Himalayas,  in  Derbyshire  and  Notting- 
hamshire, England,  and  in  certain  limited  but  not  well  denned  areas  in 
the  United  States. 

Etiology. — The  cause  cannot  be  definitely  determined;  but  the  com- 
mencement can  frequently  be  traced  to  repeated  congestion  of  the 
thyroid  body  occurring  at  the  time  of  menstruation,  or  due  to  violent 
efforts.  Goitre  is  sometimes  hereditary.  It  is  often  attributed  to  the 
drinking  of  snow  and  glacial  water,  water  impregnated  with  chalk,  or 
to  bad  air  and  bad  surroundings  and  deficient  sunlight;  but  the  preva- 
lence of  the  disease  in  places  differing  from  each  other  widely  in  atmo- 


630  DISEASES   OF  THE  THYROID   GLAND. 

sphere,  temperature,  and  surroundings,  and  in  some  of  which  the  drink- 
ing-water cannot  possibly  account  for  it,  shows  that  we  are  still  in  the 
dark  regarding  the  etiology. 

Symptomatology. — The  symptoms  depend  upon  the  amount  of  pres- 
sure exerted  upon  surrounding  structures.  The  extent  of  pressure  is 
not  necessarily  commensurate  with  the  size  of  the  tumor,  which, 
though  small,  may  send  prolongations  downward  and  backward  that 
press  upon  the  trachea  or  the  pneumogastric  or  recurrent  laryngeal 
nerves  and  cause  alteration  of  the  voice,  and  dyspnoea,  which  may  be 
slight  or  severe.  "When  dyspnoea  is  severe,  it  often  comes  on  in  parox- 
ysms due  to  acute  congestion  and  swelling  of  the  already  narrowed  tube. 
These  attacks  are  sometimes  speedily  fatal,  and  though  the  patient  may 
recover  from  one  attack  he  is  liable  to  others  during  which  the  danger  is 
great.  Pressure  upon  the  brachial  plexus  may  cause  pain,  numbness, 
or  even  paralysis  of  the  arm ;  but  there  is  seldom  any  pain  referred  to 
the  enlarged  thyroid  gland. 

Diagnosis. — There  is  usually  no  difficulty  in  the  diagnosis  excepting 
in  rare  cases,  where  small  goitres  press  posteriorly,  causing  difficulty  in 
respiration,  while  the  external  growth  may  be  hardly  perceptible.  Pressure 
upon  the  veins  causes  turgescence  and  lividity  of  the  face,  with  promi- 
nence of  the  superficial  veins  over  the  tumor,  and  passive  hyperemia  of 
the  brain.  There  is  occasionally,  though  not  often,  pressure  upon  the 
oesophagus,  which  then  causes  difficult  deglutition.  The  gland,  which 
is  connected  with  the  trachea,  rises  and  falls  during  deglutition  unless 
too  large;  the  skin  over  it  is  freely  movable,  and  the  tumor  is  not 
attached  to  the  jaw  and  does  not  involve  the  surrounding  parts.  The 
size  varies  from  slight  fulness  of  the  neck  to  an  enormous  growth.  The 
surface  is  sometimes  even,  but  often  nodular,  and  in  extreme  cases  lobu- 
lated.  The  fibro-cystic  variety,  which  is  most  common,  has  an  irregular 
surface,  firm  to  the  touch,  with  here  and  there  soft  spots  over  the  cysts. 

It  is  distinguished  from  tumors  of  other  portions  of  the  neck  by  its 
position  and  movements  during  the  act  of  swallowing.  It  is  distinguished 
from  exophthalmic  goitre  by  absence  of  the  ophthalmic  and  cardiac  signs; 
and  from  malignant  tumors  by  comparative  absence  of  pain,  and  by  not 
being  adherent  to  other  tissues  and  consequently  moving  beneath  the 
skin  and  with  the  deglutitory  movements  of  the  larynx  and  trachea. 

Prognosis. — The  tumor  usually  slowly  increases  for  many  years, 
but  is  always  a  source  of  danger,  as,  from  sudden  swelling  or  steady 
pressure,  with  acute  inflammation  of  the  lining  membrane  of  the  air 
passages,  it  is  liable  to  cause  strangulation. 

Treatment. — It  is  necessary  to  remember  that  endemic  causes  play 
a  prominent  part  in  the  etiology  of  goitre,  and  therefore  removal  to 
some  other  locality  may  be  the  most  important  measure  in  effecting  a 
cure.  If  the  tumor  is  small  or  of  medium  size,  it  may  often  be  dissi- 
pated by  iodine  in  some  form.     The  tincture  of  iodine  may  be  applied 


GOITRE.  631 

locally  to  the  neck,  and  the  remedy  given  internally  in  the  form  of 
potassium  iodide  in  doses  of  from  gr.  v.  to  gr.  xx.,  or  the  tincture  of  io- 
dine in  doses  of  TT[  v.  to  xx.  may  he  administered  in  capsules,  which  are 
taken  with  a  large  draught  of  water,  three  hours  after  each  meal.  The 
internal  use  of  the  remedy  often  fails,  and  then  injections  have  been 
practised  in  some  cases  with  excellent  results.  Here  again  iodine 
may  be  used,  but  it  is  important  that  the  solution  should  be  thoroughly 
aseptic ;  for  this  purpose  I  would  recommend  the  aqueous  solution  pre- 
pared by  J.  E.  Clark  of  Detroit  for  the  treatment  of  tuberculosis. 
Hypodermic  injections  into  the  tumor,  of  carbolic  acid  in  doses  of  Ti[  xv. 
to  lx.  of  a  three  to  five  per  cent  solution,  are  sometimes  followed  by 
excellent  results.  These  should  be  given  once  or  twice  a  week  according 
to  the  irritation  they  produce.  Injections  of  iodoform  according  to  the 
Mosetig-Moorhof  plan  are  said  to  be  safe  and  efficacious.  This  method 
consists  in  injecting  into  the  gland,  with  antiseptic  precautions,  about 
once  a  week,  from  one  to  four  grains  of  iodoform  dissolved  in  ether  and 
olive  oil  seven  parts  each.  Five  to  ten  injections  are  said  to  be  necessary 
for  a  cure. 

In  the  cystic  variety,  Mackenzie  recommends  puncturing  the  cyst, 
drawing  off  its  contents  and  injecting  the  sac  with  a  solution  of  perchlor- 
ide  of  iron,  3  ij.  ad  §  i.,  which  is  to  be  left  in  for  three  days ;  the  canula 
being  corked  and  held  in  place  by  a  strip  of  tape  passed  about  the  neck. 
The  cork  is  then  removed  and,  if  suppuration  has  occurred,  the  cyst 
should  be  thoroughly  washed  several  times  with  an  antiseptic  solution 
{London  Lancet,  May  11th,  1872).  Obliteration  of  the  sac  accompanies 
the  healing  process.  If  the  first  operation  is  not  successful,  it  should  be 
repeated  until  a  sufficiently  high  grade  of  inflammation  has  been  induced. 

Electrolysis  is  sometimes  a  very  efficient  means  of  curing  these 
cystic  growths.  It  may  be  practised  by  inserting  into  the  tumor  suita- 
ble needles  at  a  distance  of  an  inch  or  more  from  each  other  and  passing 
through  them  a  galvanic  current  as  strong  as  can  be  borne  by  the 
patient  for  ten  or  fifteen  minutes  at  each  sitting;  to  be  repeated  at  in- 
tervals of  five  or  ten  days  until  the  cyst  disappears.  If  the  tumor  presses 
upon  the  tracheia  so  as  to  interfere  seriously  with  respiration,  tracheot- 
omy should  be  done  and  a  long,  flexible  canula  introduced  and  worn 
while  the  danger  remains.  Owing  to  the  success  obtained  during  the 
last  decade,  partial  extirpation  of  the  gland  is  an  operation  which  meets 
with  considerable  favor  among  general  surgeons.  Total  extirpation 
is  a  dangerous  operation,  very  liable,  in  those  who  survive  the  immediate 
effects,  to  be  followed  by  cachexia,  strumipriva  or  myxcedema,  there- 
fore it  cannot  be  recommended.  The  operation  itself  is  fully  described 
in  recent  works  on  surgery. 


032  DISEASES  OF  THE  THYROID   GLAND. 

EXOPHTHALMIC   OOITRE. 

Synonyms, — Graves'  disease,  Basedow's  disease. 

Exophthalmic  goitre  is  a  disease  of  the  sympathetic  nervous  system 
characterized  by  enlargement  of  the  thyroid  gland,  prominence  of  the 
eyes,  disturbance  of  the  action  of  the  heart,  and  deficient  chest  expan- 
sion, though  one  or  two  of  these  symptoms  may  be  absent.  It  is  fully 
described  in  textbooks  on  practice,  and,  as  stated  in  the  previous  edition 
of  this  work,  it  belongs  to  the  domain  of  the  neurologist  rather  than  to 
the  specialist  on  diseases  of  the  throat  and  chest.  It  is  mentioned  here 
because  the  laryngologist  is  sometimes  consulted  about  it  and  to  call 
attention  to  the  remarkable  effects  sometimes  exerted  upon  it  by  the 
administration  of  the  tincture  of  strophanthus,  which  has  proven  cura- 
tive in  several  reported  cases.  Daniel  R.  Brower,  of  Chicago,  has  treated 
three  cases  by  this  agent  successfully.  I  have  cured  two  cases  by  the 
administration  of  ten-minim  doses  of  tincture  of  strophanthus  three 
times  daily  for  a  period  of  several  months,  combined  with  repeated 
injections  into  the  gland  of  thirty  minims  of  a  three  to  five  per  cent 
solution  of  carbolic  acid.     In  some  cases  it  seems  to  be  of  no  value. 


DISEASES    OF   THE    OESOPHAGUS. 

CESOPHAGITIS. 

ACUTE    OESOPHAGITIS. 

Acute  oesophagitis  is  a  comparatively  rare  affection  of  the  mucous 
membrane  lining  the  oesophagus,  characterized  by  painful  deglutition. 
The  inflammation  may  be  either  circumscribed  or  diffused. 

Etiology. — Oesophagitis  sometimes  results  from  simple  exposure 
to  cold,  in  which  case  it  is  generally  rheumatic;  it  may  be  induced  by 
the  use  of  extremely  hot  or  irritating  foods,  or  by  iced  drinks,  particu- 
larly when  the  subject  is  warm;  it  may  be  caused  by  irritating  medi- 
cines, foreign  bodies,  or  the  passage  of  surgical  instruments;  but  most 
frequently  it  results  from  swallowing  very  hot  or  corrosive  substances. 
It  is  sometimes  associated  with  diphtheria,  pneumonia,  scarlet  fever, 
small-pox,  dysentery,  cholera,  tuberculosis,  pyaemia,  or  cancer. 

Symptomatology. — In  mild  cases  there  may  be  simply  a  sense  of 
constriction  in  the  oesophagus;  but  in  those  more  severe,  pain,  which 
in  the  acute  disease  may  be  increased  by  pressure,  is  felt  deep  beneath 
the  sternum  or  in  the  back,  between  the  scapulae.  This  pain  is  experi- 
enced upon  deglutition  even  of  saliva,  and  is  much  aggravated  by  swal- 
lowing solids.  Dysphagia  or  aphagia  results  from  swelling  or  spasm 
of    the    oesophagus    during   attempted    deglutition    which    may    cause 


OESOPHAGITIS.  633 

regurgitation  of  food  and  vomiting.  The  vomited  matter  consists  of 
glairy,  sometimes  blood-stained  mucus,  together  with  the  food  that 
has  been  swallowed.  There  is  fever,  with  intense  thirst,  commonly 
accompanied  in  children  by  convulsions.  Sometimes  involvement  of 
the  larynx  causes  hoarseness,  and  cough  may  be  produced  by  the  act  of 
swallowing.  By  auscultation  while  the  patient  is  swallowing  fluid,  a 
peculiar  gurgling  sound  may  be  heard  at  the  seat  of  inflammation  pro- 
vided it  has  caused  narrowing  of  the  tube. 

Diagnosis. — The  diagnosis  will  depend  upon  the  history,  the  seat 
of  the  pain,  the  time  of  its  occurrence  and  the  presence  of  dysphagia. 

Prognosis. — In  mild  cases  the  disease  usually  subsides  within  three 
or  four  days;  in  those  more  severe  it  may  terminate  favorably  within  a 
week  or  ten  days,  but  where  there  is  extensive  inflammation  the  prog- 
nosis is  grave.  "When  associated  with  diphtheria  or  small-pox,  it  is  gen- 
erally fatal.  Phlegmonous  inflammation  of  the  cesophagus  may  cause 
death  within  two  or  three  days.  Where  recovery  occurs,  the  walls  of 
the  tube  usually  remain  more  or  less  thickened,  and  if  the  inflammation 
has  been  severe  a  stricture  results. 

Treatment. — In  mild  cases,  demulcents  should  be  employed,  and 
frequent  comparatively  large  doses  of  bismuth  subnitrate  are  valuable, 
given  in  powder  and  with  as  little  fluid  as  possible.  The  food  should 
be  liquid.  When  swallowing  is  impracticable,  food  should  be  given  per 
rectum.  In  the  early  stage,  the  sucking  of  ice,  and  the  application  of 
cold  compresses  externally,  are  useful.  In  cases  resulting  from  an  im- 
pacted foreign  body,  the  cause  should  be  removed.  In  those  resulting 
from  the  swallowing  of  acids  or  alkalies,  weak  chemical  antidotes 
should  be  administered  in  the  beginning. 

CHRONIC    OESOPHAGITIS. 

A  chronic  inflammation  of  the  mucous  membrane  of  the  cesophagus, 
with  more  or  less  thickening  of  the  walls,  is  characterized  chiefly  by 
difficulty  in  deglutition. 

Etiology. — Chronic  oesophagitis  usually  results  from  the  acute  dis- 
ease, from  the  excessive  use  of  alcohol,  from  syphilis,  or  from  impaction 
of  foreign  bodies;  but  it  may  be  due  to  extension  of  inflammation  from 
neighboring  parts,  to  pressure  of  aneurismal  or  other  tumors,  or  to  pro- 
longed congestion  occasioned  by  chronic  pulmonary  or  cardiac  affections. 

Symptomatology. — The  symptoms  resemble  those  of  the  acute  dis- 
ease, though  they  are  less  pronounced. 

Diagnosis. — The  diagnosis  depends  upon  the  history  and  symptoms. 
The  sounds  obtained  upon  auscultation  while  the  patient  is  swallowing 
are  apt  to  be  more  pronounced  than  in  the  acute  affection. 

Prognosis. — The  affection  usually  extends  over  a  considerable  time, 
and  is  liable  to  eventuate  in  stricture. 

Treatment. — The  cause  should  be  removed  if  possible,  and  any 


G34  DISEASES  OF  THE  (ESOPHAGUS. 

associated  disease  should  receive  appropriate  treatment.  Locally  the 
use  of  astringents  or  stimulants,  applied  by  means  of  a  soft  sponge  at- 
tached to  a  whalebone,  has  been  found  beneficial.  For  this  purpose, 
solutions  of  alum,  zinc  sulphate,  or  tannin,  varying  in  strength  from 
gr.  x.  to  xxx.  ad  3  i.,  or  silver  nitrate  gr.  v.  to  x.  ad  5  i.,  may  be  employed. 
Solutions  of  iodine  are  also  recommended.  Any  of  these  in  small  quan- 
tity, not  more  than  til  xv.  to  xx.  at  a  dose,  and  in  weak  solution,  may 
be  brought  in  contact  with  the  parts  by  the  act  of  deglutition.  As  the 
inflammation  subsides,  bougies  should  be  passed  at  intervals  of  one  or 
two  weeks  to  prevent  the  formation  of  stricture,  and  iu  some  cases  this 
procedure  will  be  found  beneficial  for  overcoming  a  persistent  low  grade 
of  inflammation. 

STRICTURE   OF  THE   (ESOPHAGUS. 

Stricture  of  the  oesophagus  consists  in  a  narrowing  of  the  tube,  occa- 
sionally congenital,  but  generally  as  the  resnlt  of  injury.  It  occurs  most 
frequently  in  children  or  young  adults. 

Anatomical  and  Pathological  Characteristics. — The  thick- 
ening usually  involves  the  mucous  membrane  and  connective  tissue,  and 
sometimes  the  muscular  walls  also.  It  occurs  oftenest  at  the  upper, 
narrowest  portion  of  the  tube,  and  next  in  frequency  near  the  cardiac 
orifice  of  the  stomach.  It  varies  in  degree  from  slight  obstruction  to 
almost  complete  closure,  and  rarely  involves  more  than  a  few  inches  of 
the  tube;  it  may  be  single  or  multiple,  symmetrical  or  tortuous;  the 
thickening  may  be  uniform  about  the  tube,  leaving  the  opening  in 
its  centre,  or  it  may  involve  only  a  portion  of  the  walls,  leaving  the 
opening  at  one  side.  Atrophy  of  the  wall  is  usually  found  below  the 
seat  of  stricture  if  it  is  narrow.  Collection  of  food  above  the  stric- 
ture causes  hypertrophy  first,  with  subsequent  fatty  degeneration  and 
dilatation.  As  a  result  of  this  weakening  and  dilatation  of  the  wall 
and  collection  of  food,  not  infrequently  a  large  cul-de-sac  may  be  formed 
above  the  obstruction. 

Etiology. — Stricture  is  sometimes  congenital,  but  usually  it  results 
from  acute  or  chronic  inflammation  most  commonly  excited  by  swallow- 
ing of  hot  water  or  lye,  or  the  result  of  rheumatism,  syphilis,  or  cancer. 

Symptomatology. — Except  in  traumatic  cases,  the  symptoms  usually 
come  on  gradually,  the  patient  at  first  experiencing  some  difficulty  in 
swallowing  large  boluses  of  solid  food.  As  the  obstruction  increases  and 
deglutition  becomes  more  and  more  difficult,  solids  have  to  be  taken  in 
small  boluses  and  washed  down  with  liquid.  Subsequently  the  diet  is 
necessarily  restricted  to  fluids;  and  eventually,  in  extreme  cases,  even 
these  cannot  be  swallowed.  Sometimes  the  bolus  is  regurgitated  imme- 
diately after  it  has  been  taken,  perhaps  covered  with  mucus,  pus,  or 
blood.  When  dilatation  of  the  oesophagus  has  occurred  above  the  stric- 
ture the  food  may  be  retained  for  some  hours,  finally  to  be  regurgitated 


STRICTURE  OF  THE  (ESOPHAGUS.  635 

more  or  less  decomposed  and  softened.  The  patient  is  usually  much 
depressed  and  very  nervous,  and  this  adds  to  the  tendency  to  spasm  of 
the  oesophagus,  which  not  infrequently  takes  place  during  deglutition. 
Pain  at  the  seat  of  the  stricture  is  sometimes  experienced,  and  occasion- 
ally dyspnoea  is  complained  of;  this  is  especially  likely  to  occur  in  can- 
cerous strictures  involving  the  recurrent  laryngeal  nerve.  Usually 
nothing  can  be  discovered  by  laryngoscopy  examination,  but  by  care- 
fully passing  oesophageal  bougies  the  location  and  degree  of  stricture 
may  be  determined. 

Diagnosis. — Stricture  of  the  oesophagus  is  to  be  distinguished  from 
tubercular  laryngitis,  from  tumors  of  the  pharynx,  larynx,  or  oesophagus, 
from  spasms  of  the  oesophagus,  from  paralysis  of  the  pharynx  and 
oesophagus,  and  from  the  presence  of  foreign  bodies.  The  diagnosis  is  not 
usually  difficult;  the  essential  points  are  the  history,  and  presence  of 
dysphagia,  and  regurgitation  of  food.  By  auscultation  the  seat  of  the 
stricture  may  frequently  be  located  when  the  patient  is  swallowing, 
owing  to  the  sound  caused  by  the  ascent  of  bubbles  of  air  just  above  the 
narrowest  portion ;  but  the  degree  of  stricture  can  only  be  accurately 
determined  by  the  passage  of  the  oesophageal  bougie.  For  this  purpose, 
graduated  dilators  made  of  the  same  material  as  flexible  catheters  are 
the  safest  instruments;  but  surgeons  usually  employ  an  olivary  bougie 
firmly  attached  to  a  long  whalebone  rod.  These  olivary  bougies  should 
be  of  several  sizes,  about  one  and  a  half  inches  in  length,  and  conical 
at  both  ends;  and  when  the  instrument  has  once  passed  the  stricture, 
it  should  be  carried  down  to  the  stomach  to  determine  whether  other 
strictures  exist.  Great  care  should  always  be  used  in  its  passage,  for  the 
walls  of  the  oesophagus  are  often  thin  and  friable  or  ulcerated,  and  there 
is  liability  of  perforation  with  fatal  results.  Upon  laryngoscopic  exam- 
ination, stricture  is  readily  distinguished  from  tubercular  laryngitis  and 
tumors  in  the  pharynx.  By  passage  of  the  bougie,  it  is  distinguished 
from  tumors  of  the  oesophagus,  spasm,  paralysis  or  foreign  bodies.  It  is 
sometimes  difficult  to  determine  whether  the  stricture  is  the  result  of 
simple  chronic  catarrhal  inflammation,  or  whether  it  is  of  malignant 
origin,  but  in  advanced  life  cancerous  disease  may  always  be  suspected, 
and  a  differential  diagnosis  may  usually  be  made  by  examination  of  the 
regurgitated  matter. 

Prognosis. — Non-malignant  strictures  may  continue  for  many  years, 
but  those  of  cancerous  origin  are  always  fatal,  usually  within  from  eight 
to  eighteen  months.  Strictures  due  to  simple  inflammation,  if  not  too 
narrow,  may  often  be  cured  by  persistent  dilatation;  if  not  relieved,  they 
tend  to  interfere  more  and  more  with  nutrition,  and  finally,  sometimes 
after  many  years,  they  may  cause  death  by  inanition.  Occasionally 
death  is  the  result  of  abscess  caused  by  the  pressure  of  food  in  the  dila- 
tation above  the  stricture,  or  of  tubercular  degeneration,  or  gangrene 
resulting  from  the  reduced  condition  of  the  system.     Pressure  upon  the 


636  DISEASES  OF  THE  (ESOPHAGUS 

recurrent  nerve  sometimes  causes  paralysis  of  the  abductor  muscles  of 
the  vocal  cords,  with  dangerous  or  even  fatal  dyspnoea  unless  tracheot- 
omy is  promptly  performed.  Ulceration  may  occur  into  the  trachea,  the 
bronchial  tubes,  or  into  one  of  the  adjacent  large  vessels. 

Treatment. — "When  resulting  from  chronic  catarrhal  inflammation, 
rheumatism,  or  syphilis,  the  administration  of  the  iodides  is  occasionally 
followed  by  relief.  In  malignant  cases,  opiates  must  be  given  to  relieve 
pain.  When  food  in  sufficient  quantity  cannot  be  taken,  nutritive  ene- 
mata  must  be  employed.  Dilatation  is  indicated  in  all  suitable  cases. 
In  those  of  malignant  nature  it  must  be  practised,  if  at  all,  with  the 
greatest  care,  but  as  a  rule  it  is  inadvisable. 

Charters  J.  Symonds,  of  London,  in  seventeen  cases  of  malignant 
stricture  of  the  oesophagus,  has  successfully  used,  for  keeping  the  stric- 
ture pervious,  a  gum  elastic  tube  four  to  six  inches  long  (London  Lan- 
March,  April.  1889).  This  is  funnel-shaped  above  and  closed  at 
its  lower  end,  but  has  an  opening  just  above  the  closed  extremity  like 
an  ordinary  catheter.  This  tube  is  introduced  through  the  stricture, 
upon  a  whalebone  staff,  and  has  attached  to  its  upper  end  a  strong 
silk  thread  which  is  fastened  to  the  ear.  It  may  be  left  in  situ  for 
weeks  or  months,   allowing    the    passage  of  liquid  food,  without  hast- 


t5*tLL.nnz»B0  e-  co  «  f. 


A,\AVtA^^\J>X\y^A^AAl^\^^^^ 


to 


Fig.  238. — Sands'  CEsopbagotome. 

> 

ening  the  inevitable  progress  of  the  disease.  In  other  cases  dilata- 
tion should  be  attempted  by  the  graduated  bougies  already  described, 
and  the  operation  should  be  repeated  every  two,  three,  or  four  days 
according  to  the  amount  of  irritation  produced,  time  aiways  being  al- 
lowed for  this  to  subside  before  the  next  operation.  When  an  instru- 
ment has  been  passed,  it  should  be  allowed  to  remain  for  a  few  seconds, 
as  long  as  the  patient  can  tolerate  it,  and  then  withdrawn  and  folio  wed 
by  one  of  a  size  larger.  Thus  the  largest  instrument  that  can  be  passed 
without  great  force  should  be  used  at  each  sitting;  at  the  next  an 
instrument  a  size  smaller  than  the  one  previously  introduced  should 
be  first  used  followed  by  one  or  two  larger  sizes.  If  the  dilatation 
proves  successful,  bougies  should  be  introduced  from  time  to  time  with 
diminishing  frequency,  and  the  patient  should  be  taught  to  perform  the 
operation  himself,  which  must  be  repeated  at  intervals  for  several 
months  or  possibly  years,  the  cure  usually  requiring  a  treatment  for  at 
least  six  to  eighteen  months.  When  the  stricture  is  very  narrow,  an 
cesophagotome    (Fig.  ~2-)b)  may  be  employed   for  incising  the  mucous 


SPASM  OF  THE  (ESOPHAGUS.  637 

membrane  to  allow  of  more  rapid  and  permanent  dilatation.  The  bulb 
is  to  be  introduced  beyond  the  stricture,  the  knife  slightly  protruded, 
and  the  instrument  withdrawn.  The  operation  is  attended  by  great 
danger,  and  is  liable  to  be  a  direct  cause  of  death  in  about  thirty-five 
per  cent  of  the  cases  operated  upon.  If  this  operation  is  adopted,  two 
or  three  slight  incisions  should  be  made  at  different  parts  of  the  stric- 
ture, gradual  dilatation  being  practised  subsequently.  External  cesoph- 
agotomy  and  gastrotomy  are  recommended  in  special  cases,  but  they 
come  more  properly  within  the  domain  of  general  surgery.  Electroly- 
sis has  also  been  recommended  in  the  treatment  of  stricture,  but  the 
close  proximity  of  the  oesophagus  to  the  vagus  nerve  renders  it  hazard- 
ous. A.  Fort,  of  Paris,  has  practised  it  successfully  in  several  instances, 
and  appears  to  have  obtained  considerable  benefit  even  in  malignant 
cases. 

COMPRESSION   OF  THE   OESOPHAGUS. 

Compression  of  the  oesophagus  results  from  the  pressure  of  mediasti- 
nal tumors,  which  may  be  carcinomatous,  aneurismal,  or  purulent.  It  is 
sometimes  caused  by  enlargement  of  the  bronchial  or  thyroid  glands, 
and  may  be  occasioned  by  pressure  of  the  fluid  in  pericarditis.  It  is  to 
be  distinguished  from  true  stricture,  by  the  process  of  exclusion.  The 
prognosis  and  treatment  will  depend  upon  the  etiology. 

SPASM   OF    THE   OESOPHAGUS. 

Synonyms. — Cramp  of  the  oesophagus,  oesophagismus,  spasmodic 
stricture. 

Spasmodic  contraction  of  the  oesophagus  is  sometimes  associated  with 
a  similar  condition  of  the  pharynx.  It  is  characterized  by  paroxysmal 
inability  to  swallow,  which  may  come  on  suddenly  and  as  speedily  dis- 
appear; or  it  may  continue  for  several  hours  or  at  irregular  intervals 
for  days  or  weeks.  It  is  most  frequently  seen  in  nervous  women,  but  is 
said  to  occur  at  all  ages,  and  judging  from  my  own  experience  it  is  not 
infrequent  in  men  past  middle  life.  It  may  be  associated  with  disease 
of  the  oesophagus,  but  is  usually  independent  of  it. 

Etiology. — The  attacks  are  sometimes  caused  by  attempts  to  swal- 
low certain  kinds  of  food,  but  they  are  often  brought  on  by  solid  food 
of  any  kind,  and  not  infrequently  even  by  fluids.  The  affection  is  at- 
tributed by  Cohen  to  rheumatism,  to  acute  disease  of  the  stomach, 
heart,  lungs,  uterus,  brain,  or  spinal  cord,  and  to  hysteria  and  hydro- 
phobia (Diseases  of  the  Throat). 

Symptomatology. — In  many  instances  the  spasm  comes  on  suddenly 
and  may  as  speedily  disappear,  but  in  others  the  constriction  remains, 
or  at  least  the  patient  supposes  it  to  remain,  for  many  hours  or  even 
days,  so  that  he  is  afraid  to  swallow  food.     When  sudden,  it  is  usually 


638  DISEASES  OF  THE  (ESOPHAGUS. 

followed  by  prompt  regurgitation  of  any  food  that  the  patient  attempts 
to  swallow,  and  sometimes  by  spasm  of  the  air  passages,  palpitation  of 
the  heart  or  syncope.  The  difficulty  is  usually  intermittent,  but  occa- 
sionally, as  before  mentioned,  the  constriction  remains  for  many  hours; 
indeed,  when  occurring  in  a  low  position,  it  sometimes  continues  so  long 
that  food  may  be  regurgitated  in  a  softened  and  decomposing  condition 
some  hours  after  it  has  been  swallowed,  owing  to  the  occurrence  of  dila- 
tation in  the  oesophagus  above  the  constriction.  The  seat  of  the  diffi- 
culty may  be  referred  by  the  patient  to  any  portion  of  the  oesophagus. 

Diagnosis. — The  diagnosis  is  based  upon  the  intermittent  character 
of  the  dysphagia,  and  exploration  with  oesophageal  bougies,  the  passage 
of  which  is  not  often  greatly  hindered  by  the  spasmodic  contrac- 
tion. It  is  most  likely  to  be  confounded  with  organic  stricture  or 
paralysis  of  the  oesophagus.  It  is  distinguished  from  organic  stricture 
by  the  history  and  the  ready  passage  of  the  bougie.  It  is  distinguished 
from  paralysis  by  the  history,  paralysis  usually  following  diphtheria; 
by  the  sudden  regurgitation  of  food,  which  often  takes  place  in  spasm 
but  is  not  common  in  paralysis;  by  its  intermittent  character;  and  by 
the  introduction  of  the  bougie,  which  passes  readily  in  paralysis,  and 
is  more  or  less  obstructed  in  spasmodic  stricture. 

Prognosis. — The  spasm  is  usually  transient,  and  the  liability  to  re- 
currence may  disapjoear  after  a  few  days  or  weeks;  but  in  some  in- 
stances it  continues  for  a  long  time,  and  I  have  seen  patients  who  have 
been  unable  to  swallow  satisfactorily  for  three  or  four  years. 

Treatment. — Anti-spasmodics,  as  bromides,  camphor,  valerian,  and 
asafcetida,  are  frequently  of  benefit,  and  in  most  instances  such  tonics 
as  iron,  quinine,  strychnine,  and  arsenious  acid  are  necessary;  but  the 
repeated  passage  of  an  oesophageal  bougie  will  give  more  relief  than  any 
other  measure.  Usually  it  is  necessary  to  repeat  the  operation  only 
three  or  four  times. 

Borgiotti  reports  a  case  of  oesophageal  spasm  in  a  woman  thirty -one  years 
old,  which  continued  uninterruptedly  for  five  hundred  and  thirty  days,  rarely 
permitting  the  passage  of  the  sound  or  liquid  food.  Cure  was  effected  within  a 
few  days  by  the  use  of  Verneuil's  oesophageal  dilator  (Centralblatt  fur  klinische 
Medicin,  1888). 

PARALYSIS    OF    THE   OESOPHAGUS. 

Paralysis  of  the  oesophagus  consists  of  loss  of  muscular  power,  char- 
acterized by  difficulty  in  deglutition.  It  is  said  to  be  very  common  in 
the  insane,  and  it  is  comparatively  frequent  in  old  age  or  in  those 
broken  down  by  poor  health,  and  also  as  a  sequel  of  diphtheria. 

Anatomical  and  Pathological  Characteristics. — The  lesions 
may  consist  of  changes  at  the  nerve  centres,  such  as  hemorrhage 
into  the  pons  or  the  medulla,    or  tumors  of  these  organs,  bulbar  pa- 


PARALYSIS  OF  THE  (ESOPHAGUS.  639 

ralysis,  multiple  sclerosis,  cerebral  atrophy,  and  progressive  locomotor 
ataxia;  or  of  pressure  upon  the  nerve  as  in  tubercular  enlargement  of 
the  pharyngeal  lymphatic  glands,  or  syphilitic  enlargement  of  the  cer- 
vical vertebras;  or  there  may  be  simple  muscular  weakness  without  ner- 
vous lesions,  as  observed  in  the  feeble  or  aged. 

Etiology. — The  most  common  causes  are  diphtheria,  and  simple 
muscular  weakness  from  old  age  or  ill  health.  The  affection  is  occa- 
sionally caused  by  syphilis,  tuberculosis,  lead  poisoning,  acute  fever,  and 
hysteria.  Inability  to  swallow  is  usually  observed  in  approaching  dis- 
solution some  time  before  failure  of  respiration  and  circulation. 

Symptomatology. — The  essential  symptom  is  difficulty  in  Swallow- 
ing, which  may  develop  quickly  or  slowly  according  to  the  cause.  It  is 
probable  that  complete  aphagia  is  never  present  unless  the  pharynx  is 
paralyzed  at  the  same  time.  When  due  to  hemorrhage  into  the  nerve 
centres,  it  comes  on  suddenly,  and  is  at  once  complete;  but  if  resulting 
from  tumors,  it  develops  gradually.  Following  diphtheria,  it  usually 
appears  within  three  or  four  weeks  after  the  beginning  of  the  attack, 
and  may  reach  its  full  intensity  in  three  or  four  days.  As  the  result  of 
nervous  diseases  it  is  a  rare  affection,  and  in  any  case  seldom  appears 
until  late  in  their  course.  When  of  central  origin,  it  is  sometimes  asso- 
ciated with  more  or  less  paralysis  of  the  sensory  or  motor  nerves  of  the 
i  irynx.  In  local  paralysis,  the  affection  comes  pn  gradually;  Macken- 
zie states  that  he  has  seen  several  instances  in  which  the  disease  has 
iasted  from  ten  to  twenty  years,  that  it  apparently  leads  after  a  time  to 
some  stenosis  of  the  gullet,  and  that  in  long-standing  cases  the  isthmus 
faucium,  and  even  the  mouth,  is  often  much  contracted  (Diseases  of  the 
Throat  and  Nose,  Vol.  II). 

Patients  are  commonly  very  weak,  but  emaciation  is  not  usually  a 
marked  symptom  excepting  in  cases  of  long  duration.  There  is  seldom 
any  regurgitation  of  food,  though  in  mild  cases  patients  complain  of  its 
lodging  in  the  oesophagus.  The  sound,  which  may  be  heard  during 
deglutition  over  the  normal  oesophagus  is  greatly  altered  or  may  be  sup- 
pressed by  paralysis,  so  that,  instead  of  being  distinct  as  in  health,  only 
a  trickling  or  dropping  can  be  heard.  A  bougie  may  be  passed  easily 
and  is  less  likely  to  cause  nausea  than  in  health,  but  occasionally,  in 
cases  of  long  standing,  contraction  of  the  gullet  is  said  to  occur,  causing 
much  difficulty  in  passing  the  instrument. 

Diagnosis. — Paralysis  is  to  be  distinguished  from  spasm  and  from 
malignant  diseases. 

Paralysis  is  distinguished  from  spasm  of  the  oesophagus  as  follows : 

Paralysis  of  the  cesophagus.  Spasm  of  the  cesophagus. 

Most  common  in  advanced  life  and  Most  frequent  in  the  young  and  hys- 

in  feeble  patients.  terical  subjects. 

Dysphagia  continuous.  Dysphagia  intermittent. 


640  DISEASES  OF  THE  (ESOPHAGUS. 

Paralysis  of  the  oesophagus.  Spasm  of  the  ozsophagus. 

Seldom  any  regurgitation  of  food.  Regurgitation  of  food  common 

Bougie  passed  easily,  except  in  rare  At  times  impossible  to  pass  bougie. 

cases  of  long  standing. 

No  distinct  sound  produced  by  svval-  Sharp  sound  heard  over  oesophagus 

lowing.  during  deglutition. 

We  find  that  malignant  disease  of  the  oesophagus  causes  difficulty  in 
deglutition,  and,  like  paralysis,  generally  occurs  in  advanced  life,  but  it 
is  attended  by  pain,  regurgitation  of  food,  and  constant  obstruction  to 
the  passage  of  the  bougie. 

Prognosis. — When  depending  upon  muscular  weakness,  diphtheria, 
or  lead  poisoning,  the  prognosis  is  very  favorable,  but  if  due  to  lesions  of 
the  nervous  system  it  is  grave. 

Treatment. — In  the  severe  forms,  little  can  be  accomplished  in  the 
way  of  treatment.  In  any  case  where  the  cause  can  be  found  it 
should  be  removed  if  possible.  Usually  iron,  quinine,  and  strychnine, 
especially  the  latter,  are  important  agents,  together  with  a  stimulating 
diet.  Mackenzie  recommends  faradization  of  the  oesophagus  once  or 
twice  daily,  preferably  before  meals.  The  positive  pole  should  be  placed 
by  means  of  the  necklet  in  contact  with  the  spinous  processes  of  the 
upper  cervical  vertebra?,  the  negative  attached  to  the  oesophageal  elec- 
trode, which  should  be  introduced  three  or  four  times  at  each  sitting, 
and  retained  for  a  few  seconds.  It  is  sometimes  desirable  to  feed  the 
patient  through  an  oesophageal  tube;  especially  is  this  necessary  if  the 
pharynx  and  larynx  are  also  paralyzed. 

FOREIGN   BODIES   IN    THE   OESOPHAGUS. 

Foreign  bodies,  of  great  variety,  may  become  impacted  in  the  oesoph- 
agus, where  they  interfere  with  respiration  and  deglutition.  They  gen- 
erally lodge  either  in  the  lower  portion  of  the  pharynx  or  just  below 
it  or  at  the  upper  portion  of  the  oesophagus  directly  behind  the  cricoid 
cartilage,  but  sometimes  they  pass  lower  and  occlude  the  passage  opposite 
the  bifurcation  of  the  trachea  or  just  above  the  cardiac  orifice  of  the 
stomach.  The  most  common  of  these  foreign  bodies  are  large  boluses  of 
food,  coins,  pins,  fragments  of  bone,  and  plates  with  false  teeth. 

Symptomatology. — When  foreign  bodies  are  large  and  lodged  in  the 
lower  part  of  the  pharynx,  they  may  depress  the  epiglottis  so  as  to  cause 
immediate  suffocation.  Large  bodies  may  provoke  retching  or  vomit- 
ing, and  prevent  swallowing  either  of  solids  or  fluids.  Smaller  bodies 
usually  cause  actual  pain  or  pricking  sensations,  sometimes  slight  bleed-  % 
ing,  and  frequently  interfere  with  the  swallowing  of  solids,  but  not  with 
swallowing  of  liquid.     Sharp,  irregular  bodies  cause  pain  and   inflam- 


FOREIGN  BODIES  IN  THE  ESOPHAGUS.  641 

mation.  Large  or  irregular  bodies  may  cause  cough,  spasm  of  the  glottis, 
aphonia,  or  asphyxia.  The  respiration  may  be  impeded  by  involution 
of  the  trachea  or  by  spasm. 

Diagnosis. — The  presence  of  foreign  bodies  is  to  be  distinguished 
from  globus  hystericus  and  from  paresthesia  of  the  oesophagus.  The 
essential  features  in  the  diagnosis  are  the  history,  laryngoscopic  exami- 
nation, and  exploration  with  the  bougie.  By  inspection,  affections  of  the 
pharynx  and  larynx  may  be  excluded;  and  sometimes,  in  the  case  of 
irregular  bodies,  blood  or  pus  may  be  detected  at  the  oesophageal  en- 
trance. Exploration  with  the  finger  will  sometimes  detect  a  foreign 
substance,  and  passage  of  the  oesophageal  bougie  will  usually  locate 
the  object  unless  small;  but  in  some  cases  spasm  of  the  oesophagus 
above  or  below  the  foreign  substance  seriously  interferes  with  this 
examination.  Care  must  be  taken  not  to  be  misled  by  the  dense 
pharyngo-epiglottic  ligament  and  normal  narrowing  at  the  entrance  of 
the  oesophagus.  Foreign  bodies  will  be  distinguished  from  globus  hyster- 
icus by  the  history,  by  the  presence  of  other  symptoms  of  hysteria,  by 
frequent  change  in  location  of  the  sensations  in  the  nervous  affection, 
and  by  exploration  with  the  bougie.  From  paresthesia  of  the  cescph- 
agus,  where  the  patient's  sensations  indicate  the  presence  of  a  foreign 
body,  and  where  the  history  generally  points  to  an  accident  of  this  kind, 
the  diagnosis  can  only  be  made  by  careful  exploration  with  the  bougie 
and  extractor. 

Peogxosis. — The  lodgement  of  a  foreign  body  often  proves  immedi- 
ately fatal  from  suffocation.  Sometimes  comparatively  smooth  objects 
have  remained  in  the  oesophagus  for  months  or  years  and  then  been 
removed  or  spontaneously  discharged,  but  as  a  rule  there  is  danger  so 
long  as  a  foreign  body  remains  impacted  in  the  oesophagus,  since  it  is 
apt  to  set  up  inflammation  which  may  be  followed  by  abscess;  or  the 
pressure  may  cause  ulceratibn  and  opening  into  the  mediastinum,  the 
trachea,  or  the  aorta.     Impacted  bodies  sometimes  work  their  way  to 


Fig.  339. — Flexible  (Esophageal  Forceps  (1-5  size;. 

the  surface  and  may  be  discharged  without  immediate  danger,  but  in 
this  way  they  may  give  rise  to  a  fistula.  Sometimes  they  cause  inflam- 
mation ana  caries  of  the  vertebra?,  or  secondary  disease  of  the  lungs, 
pericardium,  or  other  organs.  Perforation  of  the  oesophagus  usually 
leads  to  emphysema  of  the  neck,  and  commonly  proves  fatal.  Great 
injury  is  sometimes  unavoidably  inflicted  in  withdrawing  these  sub- 
stances. 

Kepetition  of  the  accident  is  observed  in  some  people  in  consequence 
of  spasm  of  the  constrictor  muscles  of  the  oesophagus  or  of  partial  paral- 
4i 


642  DISEASES  OF  THE  (ESOPHAGUS. 

ysis ;  but  in  such  cases  the  obstructing  bolus  may  generally  be  carried 
on  by  the  swallowing  of  another  bit  of  food  or  a  drink  of  water. 

Treatment. — Prompt  removal  of  the  body  is  desirable  in  all  in- 
stances. If  not  too  large,  it  may  be  speedily  removed  by  an  emetic,  for 
which  purpose  apomorphine,  gr.  y^,  injected  subcutaneously,  may  be 
effectually  employed.  If  the  foreign  body  can  be  seen  or  felt,  it  may 
sometimes  be  removed  by  the  finger,  blunt  hook,  or  forceps.  Even  when 
lower,  it  may  often  be  caught  with  flexible  oesophageal  forceps  (Fig.  239) 
or  with  the  bristle  extractor  (Fig.  240)  or  the  coin-catcher. 

In  several  instances  Crequy  has  succeeded  in  removing  foreign  bodies 
by  having  the  patient  swallow  a  well  lubricated  tangled  skein  of  thread 
with  a  long  stout  thread  tied  to  its  centre;  traction  is  made  upon  the 
thread  when  the  bundle  has  had  time  to  pass  the  obstruction  (Gazette 
des  Hopitaux,  1870,  No.  56). 


SHARP  &.  S'HYTH 


Fig.  240.— Bristle  Extractor  (\&  size). 

B.  Polikier,  of  Warsaw  (Revue  mensuelle  des  maladies  de  Venfance, 
Paris,  1892),  reports  two  cases  in  which  he  succeeded  in  removing  foreign 
bodies  from  the  oesophagus  in  children,  by  a  sort  of  massage  upward  and 
backward  with  the  finger  pressed  down  between  the  trachea  and  sterno- 
cleido-mastoid  muscle;  while  with  the  other  hand  he  tickled  the  child's 
throat  until  it  vomited  and  brought  up  the  foreign  body. 

When  susceptible  of  digestion,  there  is  no  objection  to  pushing  the 
foreign  body  into  the  stomach,  care  being  used  to  avoid  injuring  the 
oesophagus:  and  if  the  offending  object  be  lodged  low  in  the  passage, 
this  is  frequently  the  only  operation  that  can  be  practiced.  Fortunately 
many  indigestible  substances  may  pass  into  the  stomach  without  harm 
to  the  patient.  When  substances  are  firmly  lodged  in  the  upper  por- 
tion of  the  oesophagus,  and  cause  distressing  or  dangerous  symptoms, 
laryngotomy  or  oesophagotoray  must  be  performed.  These  operations, 
which  are  fully  described  in  textbooks  on  general  surgery,  not  infre- 
quently give  good  results. 

PARESTHESIA  OF  THE  (ESOPHAGUS. 

Parassthesia  is  a  nervous  affection  in  which  the  patient  fancies  some 
foreign  body  lodged  in  the  pharynx  or  oesophagus.  It  usually  occurs 
in  women  of  enfeebled  health,  with  nervous  temperament,  or  in  hysteri- 


PARESTHESIA   OF  THE  (ESOPHAGUS.  643 

cal  subjects.  There  are  no  anatomical  changes  in  the  parts,  but  the 
patient  fancies  she  is  unable  to  swallow  solids,  or  she  is  unwilling  to  at- 
tempt it  perhaps  from  a  Tague  fear  of  choking. 

Etiology. — Some  of  the  cases  are  neuralgic  in  character,  others 
hysterical:  some  depend  upon  derangements  of  the  digestive  system  or 
genito-urinary  tract;  others  upon  a  small  ulcer  or  fissure  in  the  pharynx 
or  oesophagus;  but  "most  frequently  the  condition  is  due  to  something 
which  has  lodged  for  a  time  in  the  oesophagus,  or,  having  inflicted  in- 
jury, has  subsequently  passed  on  through  the  alimentary  canal.  Pins, 
tacks,  fishbones,  and  other  small,  sharp  objects  are  most  likely  to  leave 
this  sensation. 

Symptomatology. — There  is  usually  a  history  of  something  swal- 
lowed, which  has  apparently  lodged  in  some  part  of  the  throat  or  oesoph- 
agus, giving  rise  to  pricking  sensations,  or  soreness,  fulness,  pressure, 
or  weight,  which  seems  to  the  patient  clearly  to  indicate  the  presence 
of  a  foreign  body.  The  seat  of  the  fancied  object  frequently  changes  by 
deglutition  or  efforts  made  by  the  patient  or  physician  to  remove  it; 
and  although  in  many  instances  the  patient  readily  swallows  large, 
solid  morsels,  she  cannot  be  convinced  that  these  would  necessarily  carry 
the  object  with  them.  Inspection  of  the  pharynx  and  mouth  of  the 
oesophagus  will  sometimes  disclose  a  small  fissure  or  ulcer  which  gives 
rise  to  the  sensation,  but  usually  it  only  reveals  to  the  physician  a  nor- 
mal condition  of  the  parts. 

Diagnosis. — One  of  the  most  valuable  points  in  the  diagnosis  is  a 
changeableness  of  the  fancied  position  of  the  object.  The  patient  is 
often  found  to  be  anaemic,  debilitated,  and  nervous,  frequently  able  to 
swallow  without  much  difficulty:  but  the  diagnosis  must  finally  be  de- 
cided by  passage  of  the  oesophageal  bougie,  or  an  extractor,  by  which 
foreign  bodies  can  be  felt  or  removed. 

Prognosis. — The  sensations  often  continue  weeks  or  months,  and  in 
some  cases  it  is  impossible  to  convince  the  patient  that  the  sensations 
are  altogether  nervous. 

Teeatmext. — Cases  depending  upon  ulceration  or  fissure  are  usu- 
ally best  relieved  by  the  application  of  solutions  of  silver  nitrate  or  the 
mineral  acids.  Those  resulting  from  having  swallowed  some  substance 
are  often  cured  by  the  passage  of  the  bougie  or  of  the  bristle  ex- 
tractor, thus  demonstrating  to  the  patient  that  nothing  can  be  lodged  in 
the  oesophagus.  Those  of  purely  nervous  origin  are  best  relieved  by 
the  same  means,  together  with  the  internal  administration  of  iron, 
quinine,  strychnine,  arsenious  acid,  and  the  bromides. 


APPEXDIX. 


FORMULAE   FOR  PRESCRIPTIONS. 

Seteral  of  the  formulae  relating  to  diseases  of  the  throat  and  nasal  pas- 
sages are  taken  from  the  Pharmacopoeia  of  the  Hospital  for  Diseases  of  the 
Throat,  London.  The  various  mixtures,  excepting  Formula  3,  which  would 
not  be  prescribed  in  quantities  of  less  than  four  ounces,  have  been  reduced 
to  the  standard  of  one  ounce ;  prescriptions  for  drugs  to  be  given  in  pill  form 
contain  quantities  sufficient  for  one  pill. 

1.  5    Morphin*  sulphatis gr.  i. 

Antimonii  et  potass,  tart gr.  i. 

Ammonii  chloridi 3  i. 

Ext.  grindelire  robust*  fluidi fl.  3  iv. 

Syrupi  pruni  Virginian*  et 

Mistur*  glycyrrhiz*  comp aa  fl.  3  ij. 

M.     S.  Teaspoonful,  for  cough.     Especially  useful  in  acute  bronchitis. 

2.  Pf.    Morphinse  sulphatis gr.  i. 

Chloralis 3  i. 

Syrupi  zingiberis       .  • 3  iv. 

Misturte  glycyrrhiz* ad  fl.  §  i. 

M.     S.  Teaspoonful    every  half-hour    until    relieved.     For   spasmodic 
asthma. 

3.  Emulsion  of  Cool-Liver  Oil. 

B   Olei  morrhute 3  ij . 

Sacchari 3  vi. 

Acacige 3  iv. 

Olei  gaultheri* tt[  xv. 

Aqua3 q.s.  ad  fl.  §  iv. 

Triturate  the  sugar  and  acacia  thoroughly  with  one-half  the  amount  of 
water  until  a  uniform  mucilage  is  formed;  then  add  the  oil  slowly,  with 
constant  trituration,  and  subsequently  add  the  remainder  of  the  water.  It 
requires  about  an  hour  to  make  the  perfect  emulsion,  to  which  may  be 
added  lacto-phosphate  of  calcium  or  phosphoric  acid,  which  will  give  it  an 
agreeable  acidulous  taste.  Chloride  of  calcium  may  be  added  when  desired, 
but  the  lactophosphate  of  calcium  is  much  more  agreeable  to  the  taste  and 
answers  a  similar  remedial  purpose. 

4.  Pi,  Potassii  bromidi gr.  xl. 

Syrupi  lactucarii  (Aubergier's) 

Syrupi  acidi  hydriodici aa  3  iv. 

M.     S.  Teaspoonful  every  four  to  six  hours.    A  most  useful  cough  medi- 
cine for  protracted  branch  itis  in  ch  ilclren. 


646 


APPENDIX. 


5.   IJ  Morphinse  sulphatis 
Ammonii  carbonatis 
Syrupi  pruni  Virginian* 
Mistime  glycyrrhizae  coinp.     . 
M.     S.  Teaspoonful  in  water,  for  cough. 
when  opiates  are  not  contra-indicated. 


.     gr.  1. 

.     gr.  xxx.  -xl, 

aa  fl.  3  iv. 
A  most  useful  cough  syrup 


6.  Pil.  Can.  Ind.,  Hyoscyam.,  et  Quinince  Comp.  (No.  1). 

B  Ext,  can.  Ind.  (Allen's) gft  \ 

Ext.  nucis  vom. gr.  £' 

Ext.  hyoscyam.  (alcoholic) gr.  i 

Camphor* gr.  i. 

Quininse  muriate gr.  iss. 

M.     S.  Before  meals  and  at  bed-time. 


Pil.  Can.  Ind.,  Hyoscyam.,  et  Quinince  Comp.  (No.  2). 

5   Ext.  can.  Ind.  (Allen's) gr.  £ 

Ext.  nucis  vom. gr.  i 

Ext.  hyoscyam.  (alcoholic) gr.  i. 

Creasoti mi. 

Dextro-quininsc gr.  ij. 

M.     S.  Before  meals  and  at  bed-time. 


Pil.  Capsicum,  Hydrastine,  Papain  Comp. 
5  Oleoresinae  capsici     . 

Ext.  nucis  vom. 

Hydrastine  muriate 

Papain  (Carica  papaya) 

Acidi  salicylici  . 
M.     S.  After  meals. 


gr.  i 
gr.  i 
gr.  iij. 
gr.  i. 


9.  lodol  Ointment. 

3  Acidi  carbohci ^l  vi. 

Olei  rosse TT,  v. 

Iodol gr.  xxv. 

Lanolini §  ss. 

M.    S.  A  valuable  ointment  for  healing  abrasions  of  the  nostril  and 
upper  lip  and  for  healing  erosions  of  the  septum. 


10.  5    Antimonii  et  potassii  tartratis gr.  xx. 

Cantharidis  et 

Olei  tiglii aa,  gr.  xl. 

Camphor*  et 

Ext,  stramonii  (aqueous) aa  gr.  lxxx. 

Adipis 3  iiss. 

Cerati  simplicis ad  1  i. 

M.     S.  Counter-irritant  ointment. 

11.  3  Tinctur*  iodi 3ss.-3i. 

Potassii  iodidi gr.  x.-xx. 

Aqua: ad  fl.  1  i. 

M.     S.  Use  as  an  injection,  which  should  be  withdrawn  in  about  five 
minutes.    For  chronic  pleurisy. 


GARGLES— TROCHISCI  OR  LOZENGES. 


647 


GARGLES. 

Gargles  are  only  useful  in  diseases  of  the  fauces.  They  cannot  affect  the 
nasal  passages,  lower  pharynx,  or  larynx.  The  preparations  may  be  seda- 
tive, astringent,  stimulant,  or  antiseptic. 


SEDATIVES. 


12.   5  Potassii  bromidi 


13.  1$  Potassii  nitratis         .... 

Potassii  chloratis       .... 

Aqua?  ferventis 

M.     S.  Use  as  hot  as  it  can  be  borne. 

ASTRINGENTS. 

14.  5  Acidi  tannici      .... 

15.  1J  Aluminis 

16.  $  Ferri  et  ammonii  sulphatis 

17.  5  Sodii  boratis       .... 

Glycerine 

Tincturse  myrrhae 

Aquas 


M. 

18.  5 

M. 

19.  5 

20.  F, 

21.  B 

22.  5 

23.  3 

24.  5 


gr.  xxx.  ad  fl.  §  i. 


gr.  xx. 
ad  fl.  5  i. 


gr.xij.-3ij.  adfl.  |i. 
gr.  viij.  ad  fl.  %  i. 
gr.  viij.  ad  fl.  3  i. 
gr.  xxv. 

Til  XXV. 
TTL  XXV. 

ad  fl.  I  i. 


STIMULANTS. 

Acidi  aeetici  dil v\  xv. 

Glycerins! •  .  Tq,  xviij. 

Aqua? ad  fl.  §  i. 


Acidi  carbolici 

Potassii  chloratis 

ANTISEPTICS. 

Acidi  carbolici  vel. 

Potassii  chloratis  (see  Stimulants  19  and  20). 

Potassii  permanganatis 

Hydrargyri  chloridi  corrosivi         .   -     . 
Aqua?  cinnamomi     .        . 


gr.  ij.-x.  ad  fl.  |i. 
err.  x.-xxv.  ad  fl.  5  i. 


gr.  ij.-iv.  ad  fl.  §  i. 
gr.  i-gr.  ss.  ad  fl.  3  i. 
q.s. 


TROCHISCI   OR  LOZENGES. 

Each  lozenge  contains  seventy  to  eighty  per  cent  of  red-currant  fruit  paste, 
one  to  two  per  cent  of  powdered  tragacanth,  four  per  cent  of  sugar,  and  a 
varying  quantity  of  the  medicament  according  to  the  following  formulae : 

SEDATIVES. 

25.  Troch.  morphine  sulphatis  .        .        .        .  gr.  3^  ad  troch. 

26.  Troch.  ext.  opii gr.  ^  " 

27.  Troch.  sodii  boratis gr.  iij.  "         " 

28.  Troch.  ammonii  chloridi gr.  ij.  " 

29.  Troch.  lactucarii  (Aubergier's) 

S.    One  every  half-hour  or  hour  as  needed.     These  are  very  pleasant  to 
take  and  efficient  in  mild  cases. 


G48 


APPENDIX. 


30.  Troch.  chlorodyne 

31.  Troch.  Lobe  I  iir  Compound 
B  Aimnunii  ehloridi  . 

Ext.  lobelia?     . 
Ext.  glycyrrhizae    . 
Codeinse  . 


ttj,  v.  ad  troch. 


33. 


gr.  i. 

gr.  tV 

gr.  i. 

gr.  ^  ad  troch. 


Troch.  Morphia.  Antimony  et  Ipecac  Compound. 

ll   Morphinae  hydrochloratis gr.  ^ 

Antimonii  sulph .         •     gr.  to 

Pulv.  ipecac Er-  tu 

Olei  sassafras 

Balsam  tolu 

Ext.  glycyr.,  acacia?  et  sacch.  alb.  .         .         .         aa  q.s.  ad  troch. 

Troch.  Terpin  Hydrate  and  Cannabis  Compound. 
B  Terpin  hydrate 
Ext.  can.  ind.     . 


Codeine 

01.  menth.  pip. 

Sacch. 


gr.  ij- 
gr.  its 
gr.  i 

gr-  hj. 


34.  B   Troch.  Mist.  Glycyrrhizce  Compound. 

Same  as  mist,  glycyrrhizae  conip..  U.  S.  P. 

35.  Troch.  Opii  et  Anisi  Compound. 

B  Pulv.  opii gr-  to 

Olei  anisi,  ext.  glycyrrhi.  a?,  acacis,  et  sacch.  alb.      q.s.  ad  troch. 


DEMULCENTS. 

36.  Troch.  Althece. 

B   Althe«,  acacia3,  et  sacch.  alb. 

37.  Troch\  VI mi. 

ll   Mueil.  ulmi  cort.,  albumen  ovi.  acacia? 

Sacch.  alb., aa  q.s.  ad  troch. 

ASTRINGENTS. 

38.  B  Krameri* gr.  iij.  ad  troch. 

39.  B   Kino gr.  ij.     " 

40.  B   Acidi  tannici gr.  iss. 

41.  Troch.  Krameria  Compound. 

E  Pulv.  cubebae gr.  i 

Ext.  krameri* gr.  i. 

Potassii  chloratis gr.  ij.  ad  troch. 

STIMULANTS. 

42.  B   Acidi  benzoici gr.  iij.        ad  troch. 

43.  B  Cubebae gr.  ss. 

44.  B   Guaiaci gr.  ij.-iij.    ' 

45.  B  Pyrethri gr.  i. 


VAPOR  INHALATIONS. 


649 


46. 

Troch.  Acid  Benzoic  Compound. 

•     gr-  i 

Acidi  benzoici 

■     gr.  i 

Potassii  chloratis 

.     gr.  ij.  ad  troch. 

47. 

Troch.  Cubeb  and  Potassium  Chlorate. 

I£   Cubebae 

•     gr.  i 

Potassii  chloratis 

.     gr.  iij.  ad  troch. 

48. 

Troch.  Ammonium  Compound. 

~B,  Ext.  glycyrrhizse 

•    gr.  i 

Cubebge 

■     gr.  i 

Pulv.  ulrui  cort. 

■     gr.  i. 

Ammonii  chloridi 

•     gr.  iij. 

Acaciee  et  sacch.  alb.         .... 

.     q.s.  ad  troch. 

49. 

Guaiac  and  Ammonium  Compound. 

~Bf  Ammonii  chloridi 

•     gr.  i. 

Guaiaci  resinse 

•     gr.  i. 

Potassii  chloratis 

.     gr.  ij.  ad.  troch 

Potassium  chlorate  is  more  pleasant  and  more  efficacious  in  compressed 
pills  than  in  troches. 


ANTISEPTICS. 

50.  J}  Acidi  carbolici 

51.  ty  Potassii  chloratis  (see  Stimulants  19,  20). 


gr.  i.  ad  troch. 


VAPOR  INHALATIONS. 

Mackenzie's  eclectic  inhaler  is  the  most  complete,  but  some  of  the  cheaper 
instruments  will  answer  the  same  purpose.  An  inhaler  which  is  in  common 
use  consists  of  a  glass  flask  holding  about  a  quart.  This  has  a  perforated 
cork,  through  which  two  glass  tubes  are  passed,  one  to  the  bottom  of  the 
flask  to  admit  the  air,  and  the  other,  through  which  the  patient  inhales 
the  vapor,  into  its  upper  part.  In  the  absence  of  an  inhaler  an  earthen  tea- 
pot may  be  employed.  I  sometimes  place  the  medicine  in  a  pint  of  water  in 
a  small  tin  pan  which  is  then  covered  by  a  cone  of  paper  from  the  top  of 
which  the  patient  inhales.  The  inhalations  are  prepared  by  adding  a  tea- 
spoonful  of  the  medicated  solution  to  a  pint  of  water,  at  a  temperature  of 
about  150°  F.  or  as  indicated  by  the  formula.  They  should  be  used  morn- 
ing and  evening  for  about  five  minutes  each  time,  six  respirations  being 
taken  per  minute. 

The  oleaginous  or  balsamic  remedies  should  be  rubbed  up  with  light  car- 
bonate of  magnesium,  in  order  to  maintain  their  suspension  in  the  water,  as 
shown  in  the  following  formula : 

52.  I?   Olei  cajuputi ni  viij. 

Mag.  carb.  lev. gr.  v. 

Aqua ad  fl.  3  i. 

M.     S.  A  teaspoonful  in  a  pint  of  water  at  150°  F.,  for  each  inhalation. 
The   vapors  may  be  sedative,  antispasmodic,    antiseptic,    or  gently    or 
strongly  stimulant. 


050 


APPENDIX. 


SEDATIVES. 


53.  1$  iEtheris  et  alcoholis, 

54.  ~Bf  Chloroformi  et  alcoholis 

55.  Bf  Lupulinae     . 

56.  3}  Ext.  belladonnae  vel 

Ext.  strainonii  . 

57.  1$  Ext.  opii      . 

58.  1$  Tinct.  benzoini  conip. 

59.  J}  Tinct.  opii  camph.     . 


ANTISPASMODICS 

60.  I?   iEtheris  vel  chloroformi  (as  in  53,  54). 

61.  J$  Amyl  nitritis 


aa 
aa 
.     gr.  xxx. 

gr.  v.  ad  fl.  3  i. 
gr.  v.  ad  fl.  3  i. 
fl.  3i. 
fl.  3i. 


tti  viij.  ad  fl.  3  i. 


MILD  STIMULANTS. 


62.  J^   Olei  pini  sylvestris 

63.  1$   Olei  cubebae 

64.  1$   Olei  cassiae 

Olei  limonis 
M. 

65.  I?   Olei  anisi 


tii  xl.  ad  fl.  §  i. 

3  ss.  ad  fl.  3  i. 

nivi. 

tti  x.  ad  fl.  3  i. 

tii  vi.  ad  fl.  §  i. 


66.  3    Olei  myrti m  vi. 

Camphoise gr.  v.  ad  fl.  \  i. 

M. 

67.  1}   Terebene 3  i. 

Alcoholis 1  i. 

M. 

68.  More  stimulating  than  the  above,  and  antiseptic. 

J^   Acidi  carbolici gr.  xx.  ad  fl.  3  i. 

69.  ~R,  Creasoti tti  xl.  ad  fl.  3  i. 

70.  I*  Olei  cari tti  vi.  ad  fl.  |  i. 

71.  1$  Olei  juniperi tti  xx.  ad  fl.  1  i. 

72.  ~Bt  Acidi  carbolici gr.  xxx. 

Ammonii  chloridi gr.  xxx. 

Glycerin* 3  i. 

Aquae  dest §  i. 

M. 


73.  I?  Tinct.  iodi  comp. 

Glycerin*  . 
Aquae  dest. 
M. 

74.  3   Creasoti 

Glycerinae  . 
Aquae  dest. 
M. 


tti  v. 
3i. 
3  vij. 


.     3  ss. 

.      3ij. 

q.s.  ad  f  i. 


SPRAY  INHALATIONS.  651 

To.  R    Hydrargyri  chloridi  corrosiv xt^ 

•jlycerinje 3  ij. 

Aqua?  dest. §  i. 

M. 

STRONG-  STIMULANTS. 

76.  R;   Olei  calami  arom m  v.  ad  fl.  3  i. 

77.  R  Olei  caryophylli m  x.  ad  fl.  3  i. 

78.  R   Tinct.  iodi  eornp ^l  x. 

S.  Repeat  two  or  three  times  at  each  inhalation. 

79.  R  Aquae  ammonia  et  aquae aa fl.  3  iv. 

SPRAT  INHALATIONS. 

Spray  inhalations  are  to  be  used  by  the  physician  or  patient  in  full 
strength,  with  the  compressed-air  atomizer ;  the  aqueous  solutions  may  be 
used  in  about  double  strength  by  the  steam  atomizer.  These  applications 
are  useful  principally  in  treating  diseases  of  the  fauces  and  of  the  nasal 
cavities.  It  is  almost  impossible  for  the  patient  to  draw  them  into  the 
larynx.  The  inhalations  maybe  classified  as  sedatives,  astringents  and  stim-. 
ulants.  haemostatics,  and  antiseptics. 

SEDATIVES. 

80.  R   Potassii  bromidi gr.  xx.  ad  fl.  §  i. 

81.  R    Cocainse  hydroehloratis    .        .        .        .     gr.  xl.  to  lx.  ad  fl.  §  i.. 
M. 

82.  R   Ext.  pinus  canadensis  dest 3  ss. 

Olei  geranii t^L  iv, 

Olei  petroling  vel  liquid  albolene  .        .    q.s.  adfl.fi. 

IT. 

83.  R   Antipyrini gr.  x. 

Zinei  sulph gr.  ij. 

Ext.  hamamelidis 3  i. 

Aquae  dest, q.s.  adfi. 

M. 

84.  R   Acidi  carbolici gr.  iiss, 

Mentholis gr.  v. 

Liquid  albolene 1  i. 

M. 

85.  R  Acidi  hydrocyanici  dil.      .        .        .        \        .     3  ss.  ad  fl.  3  i. 
To  be  used  only  as  a  cold  spray. 

86.  R   Acidi  carbolici gr.  i. 

Sodii  boratis 

Sodii  bicarb aa  gr.  ij. 

Grlycerinae 3  i. 

Aquas  dest. q.s.  ad|i, 

M. 

87.  R^    Olei  petrolinte  vel  liquid  albolene. 


652 


APPENDIX. 


88. 

K 

Acidi  tannici 

89. 

K 

Zinci  sulphatis   . 

90. 

K 

Zinci  ehloridi 

91. 

$ 

Aluminis     . 

92. 

V 

Ferri  perchloridi 

m.  r 


M. 
94.  3 


M 

95.  3 


ASTRINGENTS  AND  STIMULANTS. 

gr.  iij.  ad  fl.  §  i. 

gr.  ij.-x.  ad  fl.  §  i. 

gr.  ij.-x.  ad  fl.  §  i. 

gr.  x.  ad  fl.  I  i. 

gr.  iij.  ad  fl.  §  i. 

Morph.  sulph gr.  iv. 

Acidi  tannici 

Acidi  carbolici aa  gr.  xxx. 

Glycerin* 

Aqu«  dest aa  fl.  §  ss. 

Acidi  tartarici gr.  i. 

Acidi  carbolici 

Zinci  sulph •  .        .  aft  gr;  ij. 

Aqua?  dest. fl.  3  i. 

Acidi  tartarici gr.  ij. 

Zinci  sulph. gr.  xv. 

Aqua?  dest. fl.  3  i. 


M. 

96.  I?   Acidi  tartarici 

Zinci  sulph. 
Aqu«  dest. 
M. 

97.  1}   Acidi  tartarici 

Zinci  ehloridi 
Aqua?  dest. 
M. 


gr.  iij . 
gr.  xxx. 

fl.  si- 


gr-  ij. 
gr.  xv. 
fl.  I  i. 


98.  ^ 


Acidi  tartarici 
Zinci  ehloridi 
Glycerinae  . 
Aqua?  dest. 


M. 

99.  Bf   Ext.  hamamelidis  dest. 
100.  1$    Acidi  carbolici     . 
Glycerin*     . 
Aqua?  dest. 


gr.  ii J. 
gr.  xxx, 
3  iij. 
Mi- 


Cupri  sulphatis 
Aquae  dest. 


M. 

101.  3 

M. 

102.  3    Cupri  sulphatis 

Aqua-  dest. 
M. 

103.  3 


M. 


Acidi  carbolici    . 

Ext.  pinus  canadensis  dest 

Liquid  albolene 


gr.  xl. 

3i. 

5i. 


gr.  x. 

fl.  =  i. 


gr.  xx. 
fl.§i. 


gr.  xxx. 
ni  xx. 
q.  s.  ad  fl.  3  i. 


SPRAY  INHALATIONS. 

104.  1$    Acidi  carbolici    .  .......  gr.  ijss. 

Mentholis     . gr.  v. 

Liquid  albolene fl.  1  i. 

M. 

105.  I£    Acidi  carbolici tti  i. 

Mentholis gr.  i. 

Olei  gaultheriae  .        .        .        .        .        .        .  tu  i. 

Liquid  albolene fl.  3  i. 

M. 

106.  3    Olei  caryophyl .        .  tti  v. 

Liquid  albolene fl.  1  i. 

M. 

107.  I£    Olei  caryophyl ^l  viij. 

Terebene .        .  tti  xx. 

Liquid  albolene q.s.  ad  fl.  §  i. 

M. 

108.  IJ    Fl.  ext.  thuja  occidentalis. 

109.  I£    Aluminis  pulv gr.  xxx. 

Grlycerini 3  iv. 

Aquae  dest q.s.  ad  fl„  S  i. 

M. 

HEMOSTATICS. 

110.  I£    Ferri  chloridi gr.  v.  ad  fl.  3"  i. 

111.  I£    Acidi  tannici        . gr.  x.  ad  fl.  §  i. 

112.  IJ    Liquor,  ferri  chloridi 3  ij. 

Aquse  dest. q.s.  ad  fl.  §  i. 


653 


ANTISEPTICS. 


113.  1$  Sodii  benzoatis    . 

114.  I£  Aquse  calcis 

115.  3$  Bromini 

116.  ~Rf  Acidi  lactici 

117.  ^  Potassii  permanganatis 

118.  J$  Potassii  chloratis 

119.  I£  Acidi  borici 

120.  IJ  Listerine 


3  i.  ad  fl.  §  i. 
fl.§i. 

gr.  ss.  ad  fl.  §  i. 
ttl.  xx.  ad  fl.  3  i. 
gr.  v.  ad  fl.  3  i. 
gr.  xx.  ad  fl.  §  i. 
gr.  x.  ad  fl.  §  i. 
3  i.-ij.  ad  fl.  §  i. 


121.  1$    Hydrogen  perioxiduni. 

This  is  used  in  full  strength  as  purchased  at  the  drug  store,  or  diluted  with 
one  or  two  parts  of  water,  according  to  the  amount  of  smarting  produced. 


122.  1$    Acidi  tartarici 

Hydrarg.  chlorid.  corrosiv. 
Aquae  dest. 
M. 


gr.  iss. 
gr.  ss. 
fl.!i. 


654  APPENDIX 

DRY   INHALATIONS. 

Dry  inhalations  are  composed  of  substances  which  volatilize  at  ordinary 
temperatures,  or  simply  by  the  heat  of  the  hand.  They  may  be  used  with 
any  of  the  instruments  which  are  ordinarily  used  for  vapor  inhalations,  or 
they. may  be  easily  inhaled  from  a  small  wide-mouthed  bottle  in  the  bottom 
of  which  the  medicine  has  been  placed  on  a  sponge. 

One  of  the  simplest  and  most  efficacious  inhalers  for  dry  preparations 
consists  of  a  glass  tube  about  four  or  five  inches  in  length,  open  at  both  ends, 
and  holding  a  small  sponge  at  its  middle.  The  remedy  is  dropped  on  the 
sponge,  and  air  is  inspired  through  the  tube. 

When  the  substances  are  used  with  the  small  glass-tube  inhaler,  the 
amount  given  for  each  inhalation  should  be  divided  into  three  or  four  parts 
which  are  to  be  used  successively. 

If  the  effect  is  only  needed  in  the  throat  and  nose,  the  solution  may  be 
concentrated  so  that  the  same  amount  of  medicine  will  be  obtained  without 
repeatedly  charging  the  inhaler.  In  this  case,  the  patient  should  not  inspire 
deeply,  and  only  two  or  three  inhalations  should  be  taken  per  minute. 
These  inhalations  may  be  sedative  or  stimulant. 

SEDATIVES. 

123.  R    Acidi  hydrocyanici  diluti fl.  3  i.  ad  fl.  %  i. 

S.  A  teaspoonful  at  each  inhalation. 

124.  R    iEtheris.     S.  A  half-teaspoonful  at  each  inhalation. 

125.  R    Amyl  nitriti H  i. 

Alcoholis HI  xxx. 

M.     S.  Use  at  each  inhalation.     This  is  useful,  especially  in  spasmodic 
affections. 

126.  R    Olei  santali  albi mi. 

Alcoholis tti  xxx. 

M.     S.  To  be  used  at  each  inhalation  in  divided  doses. 

127.  R    Chloroformi fl.  3  ss. 

S.  To  be  used  at  each  inhalation  ;  to  be  breathed  slowly. 

STIMULANTS. 

128.  R    Tinct.  iodi m  x.-xxx. 

In  this  same  category  may  be  included  the  carbonate  of  ammonium  and 
camphor,  used  as  smelling-salts;  and  nascent  chloride  of  ammonium,  used  by 
any  of  the  inhalers  constructed  especially  for  that  purpose. 

FUMING  INHALATIONS. 

Fuming  inhalations  are  prepared  by  saturating  bibulous  paper  with  a 
solution  of  the  remedy  of  a  given  strength,  drying  the  paper,  and  then  cut- 
ting it  into  twenty  equal  parts,  each  of  which  will  contain  one  twentieth  of 
the  amount  of  medicine  used.  These  strips  may  be  rolled  into  cigarettes,  or 
they  may  be  burned  under  a  funnel  which  will  conduct  the  smoke  to  the 
mouth.  They  are  employed  in  asthma  and  spasm  of  the  larynx.  The  prin- 
cipal medicines  employed  in  this  manner  are  : 

129.  R    Potassii  arseniatis gr.  xv. 

130.  R    Sodii  arseniatis gr.  xx.-xl. 

131.  R    Potassii  nitratis gr.  xxx.-lx. 

Aqua? ad  fl.   3  i. 


PIGMENTS.  Coo 

The  three  latter  may  be  modified,  as  recommended  in  the  Throat  Hospital 
Pharmacopoeia,  by  the  addition  of  various  volatile  principles.  These  vola- 
tile substances  are  added  by  moistening  the  nitre  paper  in  a  tincture,  or,  in 
the  case  of  volatile  oils,  in  a  solution,  of  one  part  of  the  oil  to  nine  parts  of 
alcohol,  and  then  exposing  the  paper  to  the  air  a  few  minutes  to  allow  the 
alcohol  to  evaporate.  The  papers  must  be  freshly  prepared  and  kept  in 
tinfoil.     The  following  are  the  preparations  most  useful: 

SEDATIVES. 

132.  Nitrated  papers  with  tinct.  benzoini  comp. 

133.  Nitrated  papers  with  tinct.  hyoscyami  vel  stramonii. 

134.  Nitrated  papers  with  oleum  santali. 

135.  Nitrated  papers  with  oleum  sumbuli. 

STIMULANTS. 

136.  Nitrated  papers  with  spts.  camphors. 

137.  Nitrated  papers  with  oleum  cinnamomi. 

138.  Nitrated  papers  with  oleum  cassise. 

PIGMENTS. 

The  name  pigments  is  given  to  the  various  mixtures  which  are  designed  for 
topical  application  by  means  of  a  brush,  a  probang  wound  with  cotton,  or  by 
the  compressed-air  atomizer ;  the  latter  is  now  almost  invariably  employed  in 
preference  to  the  brush  or  probang.  They  may  be  prepared  with  water  or 
with  glycerin,  but  it  should  be  remembered  that  the  latter  is  irritating  to 
some  throats.  The  pigments  may  be  anaesthetic,  astringent,  stimulant,  or 
antiseptic  in  their  effects. 

LOCAL    ANiESTHETICS. 

139.  R  Morphinae  sulphatis    : gr.  iv. 

Acidi  carbolici gr.  xxx. 

Glycerini fl.  1  i. 

M. 

Thirty  grains  of  tannin  may  be  added,  when  a  slightly  astringent 
effect  is  desired. 

140.  I?  Atrophias gr.  ^ 

Strophanthin gr.  A 

Olei  caryophylli .  lTl  iij. 

Acidi  carbolici      .        ...        .         .        .  gr.  x. 

Cocainae  hydrochloratis gr.  xx. 

Aquae  dest fl.  3  i. 

M. 

141.  R  Chloral .        .        .         3  i. 

Aquae ad  fl.  1  i. 

M. 

142.  R  Morphinae  sulphatis    .        .        .        .        .        .        gr.  xx. 

Chloroformi ad  fl.  %  i. 

M. 

143.  R  Sol.  cocainae 10%  to  25$ 

This  solution  is  rarely  used  for  any  other  purpose  than  that  of  produc- 
ing anaesthesia  of  the  faucial  surfaces — where  the  throat  is  hyper-sensitive — 
to  facilitate  an  examination  of  the  pharyngo-larynx. 


656 


APPENDIX. 


144. 
145. 
146. 

147. 
148. 


149. 
150. 
151. 
152. 
153. 
154. 
155. 

156. 
157. 
158. 
159. 
160. 


ASTRINGENTS. 

~B,  Zinci  ehloridi 

R  Zinci  sulphatis 

I£  Ferri  et  auimonii  sulphatis 

~B,  Liquor  ferri  ehloridi    . 

R  Aeidi  tannici 

Glyeerini        .... 
M. 

STIMULANTS   AND   CAUSTICS 

K  Zinci  ehloridi 

~R,  Cupri  sulphatis    . 

~B,  Liquor  ferri  ehloridi    . 

~B,  Argenti  nitratis    . 

~B,  Liquor  hydrargyri  nitratis 

I?  Tinct.  iodi     .... 

n  lodi         

Glyeerini       .... 
M. 

1$  Argenti  nitratis    . 
R  Argenti  nitratis    . 
R  Argenti  nitratis    . 
3  Tinct,  iodi. 
R  Liquor  iodi  couip. 


ANTISEPTICS. 


161.  1$  Aeidi  carboliei 


gr.  x.  ad  fl.  1  i. 

gr.  x.-xxx.  ad  fl.  %  i. 

gr.  xxx.  ad  fl.  §  i. 

tti  xl.  ad  fl.  3  i. 

3ij. 
ad  fl.  I  i. 


gr.  xxx.  ad  fl.  3  i. 
gr.  xx.  ad  fl.  3  i. 
fl.  l  ij.  ad  fl.  3  i. 
3  ss.  to  3  i.  ad  fl.  §  i. 
Tq.  xl.  to  3  ij.  ad  fl.  §  i. 

?i. 

gr.  xxx. 

ad  fl.  3  i. 

gr.  lx.  ad  fl.  3  i. 
gr.  xl.  ad  fl.  3  i. 
gr.  x.  ad  fl.  3  i. 


gr.  xxx.  ad  fl.  1  i. 


INSUFFLATIONS. 

Powders  have  been  extensively  used  in  the  treatment  of  nasal  and  laryn- 
geal affections.  I  am  accustomed  to  dilute  most  of  the  drugs  which  I  em- 
ploy in  powdered  form  with  from  one  to  four  parts  of  sugar  of  milk,  acacia, 
or  starch.  Of  the  following  powders,  two  or  three  grains  are  used  at  each 
insufflation. 

SEDATIVES. 

162.  'B,  Bismuthi  carbonatis. 

163.  R  Morphine  sulphatis gr.  £-gr.  i 

Bismuthi  carbonatis gr.  ij. 

M. 
Tannin  or  iodoform  may  be  added. 

164.  R  Morph.  sulph gr.  iv. 

Bismuthi  subnit 3  iv. 

Amyli 3  i. 

M. 

165.  R  Morphine gr.  v. 

Iodol 

Bismuthi  subnit. 

Sacch.  lact.  aa  gr.  xxx. 

M. 


INSUFFLATIONS.  657 

166.  ~R,    Sodii  biearbonatis 

Sodii  boratis aa  gr.  iss. 

Amyli gr.  i 

Cocainfe  hydrochloratis gr.  iv. 

Saech.  lact.  .        .        .        .        .        .        .  q.  s.  ad  gr.  C. 

M. 

167.  ~Rf    Cocaine  hydrochloratis gr.  x. 

Atropine      .        . gr.  i 

Mag.  earb.  levis gr.  xv. 

Sacch.  lact. q.  s.  ad  gr.  D. 

M. 

168.  1^    Cocaine  hydrochloratis     .        .        .        .        .        gr.  x. 

Atropine gr.  -J- 

Morph.  sulph. 

Mag.  carb.  levis aa  gr.  xv. 

Sacch.  lact .        .        q.  s.  ad  gr.  D. 

M. 

ANTISEPTICS  AJtD  STIMULANTS. 

169.  I£    Acidi  borici 

170.  3    Iodol 

171.  3    Iodoforrui 

Acidi  borici         .        .        „        ,        .        ,        .        aa  gr.  1. 
M. 

172.  ^    Iodoforrni gr.  1. 

Bisrnuthi  subnit. 

Benzoini  res.        .  aa  gr.  xxv. 

M. 

173.  3    Iodoforrni. 

ASTRINGENTS  AND  STIMULANTS. 

174.  I£    Hydrastum  muriatis gr.  xxv. 

Acaciae .        q.  s.  ad  gr.  C. 

175.  I£   Pulv.  res.  myrrha3. 

176.  I£  Morph.  sulph gr.  v. 

Acidi  tannici „  gr.  xxv. 

Pulv.  Andersonii        .        ,        .        „        .        .  §  i. 
M. 

177.  ^    Benzoini  res. 

Bismuthi  subnit.        .  aa  gr.  1. 

M. 

178.  ^   Bismuthi  subnit. 

179.  3    Hyd.  chlor.  mitis. 

180.  3    Aluminis 

Sacch.  albi  .        .        .        ,        .        ,        .        „        aa  gr.  1. 
M. 

181.  3$  Antipyrin. 

Cocain*  hydrochloratis    .        .        .        .        .        aa  gr.  x. 
Mag.  carb.  levis  ...».,.        gr.  xv. 
Sacch.  lact.  .        .        .        ,        .        „        ,        q.  s.  ad  gr.  D. 

M. 

42 


658 


APPENDIX. 


NASAL  DOUCHES. 

The  following  preparations  may  be  used  as  insufflations  or  by  the  anterior 
or  posterior  nasal  douche  or  syringe,  for  detergent  or  antiseptic  purposes. 
They  should  always  be  used  warm,  and  may  be  followed  by  more  potent 
remedies.  The  amount  given  below  should  be  added  to  a  pint  of  water  at 
blood  heat,  and  part  or  all  of  it  used  at  each  application. 

182.  3  Sodii  chloridi 

183.  ^  Sodii  bicarbonatis 

184.  1^  Potassii  permanganatis 

185.  I£  Acidi  carbolic! 

186.  ~S,  Zinci  sulpho-carbolatis 

187.  Salicylate  Wash. 
'St,  Sodii  salicylates 

Sodii  biboratis 
Sodii  bicarbonatis 
Sodii  chloridi 
M.     S.    3  i.  ad  aqu«  tepidaj  0  i. 


3  i 

3  i- 

gr. 

iii. 

£»•• 

XXV 

gr. 

XXV 

a  a 

I  vi. 

iia 

3  x. 

INDEX. 


It  has  been  deemed  best  to  give  a  synopsis  of  the  articles  on  each  disease  and  its  differentiations, 
using  abbreviations  that  ivill  need  no  explanation  to  the  profession. 


Abdominal  breathing,  11 
Abscess,  infraglottic,  due  to  syphilis,  430 
of  the  larynx,  illus.,  429,  430 

symp. ,    429 ;   diag. ,  ■  prog. ,    treat. ,  430 ; 
diff.  fr.  croup;  fr.  retro-pharyngeal 
abscess,  fr.  acute  catarrhal  inflamma- 
tion, fr.  oedema.  430 
of  the  lung,  129-131 

symp. ,  129 ;  diag. ,  130 ;  prog. ,  treat. ,  131 ; 
diff.    fr.    bronchitis,  fr.    pneumonia, 
fr.  pleurisy,  130 
of  the  nasal  septum,  603 

diff.  fr.  cancer,  573;  fr.  hasmatoma,  602 
of  the  tonsils,  syn.  of   phlegmonous  ton- 
sillitis, 368 
retropharyngeal,  383-386 
Abscission  of  the  uvula,  359 
Accentuation  of  the  heart-sounds,  192 
Acute  and  subacute  bronchitis,  89,  90 
anat.,  path.,  etiol.,  symp.,  89 
catarrhal  laryngitis,   syn.  of  acute  laryn- 
gitis, 394 
cold  in  the  head,  syn.  of  acute  rhinitis,  522 
coryza,  syn.  of  simple  acute  rhinitis,  522 
endocarditis,  219-222 

syn..  anat.,   path.,  219;   etiol.,  symp., 

diag.,  220;  prog.,  treat.,  221 
diff.  fr.  pericarditis,  220 
follicular    glossitis,    symp.,   diag.,   prog. 

treat.,  347 
follicular  pharyngitis,  339,  340 

anat.,  path.,   etiol.,  symp.,  diag.,  339; 

prog.,  treat.,  340 
diff.  fr.  simple  acute  sore  throat,  339 
follicular  tonsillitis,  diff.  fr.  mycosis,  376, 

377 
inflammation   and   oedema   of   the  uvula, 

treat.,  358 
laryngitis,  394-397 

syn.,  anat.,   path.,  etiol.,    symp.,    394; 

diag.,  395;  prog.,  treat.,  396 
diff.  fr.  spasm  of  the  glottis,  fr.  croup, 
fr.  paralysis  of  the  vocal  cords,  fr. 
foreign  bodies,  395,  396;  fr.  croup, 
414 ;  fr.  retropharyngeal  abscess,  430 
miliai-y  tuberculosis,  165-167  [166 

anat.,  path.,  etiol.,  165;  symp.,  diag., 
diff.  fr.  other  forms,  166,  167 
myocarditis,  231 

nasal  catarrh,  syn.  of  simple  acute  rhini- 
tis, 522 


Acute  oesophagitis,  632,  633 

etiol.,  symp.,  632;  diag.,  prog.,  treat., 
633 
pericarditis,  212 
pleurisy,  61-72 

etiol.,    symp.,    62;    diag.,    68;    prog., 

71 ;  treat. ,  72 
diff.   fr.  pleurodynia,    fr.   pericarditis, 
fr.  pneumonia,  fr.    phthisis,  fr.    col- 
lapse of  the  lung",  fr.  cancer,  fr.  hy- 
pertrophy of  the  liver  and  spleen,  68- 
71 :   f r.  abscess  of  the   lung,  130 ;   fr. 
angina  pectoris,  251 
pneumonia,  syn.  of  lobar  pneumonia,  113 
rheumatic  sore  throat,  316,  317 

anat.,  path.,  etiol.,  symp.,  316;  diag., 

prog.,  treat.,  317 
diff.  fr.  acute  sore  throat,  312,  323 
rhinorrhea,  syn.  of  simple  rhinitis,  522 
sore  throat,  311-314 

syn.,  anat.,  path.,   etiol.,   symp.,  311; 

diag.,  312;  prog.,  treat.,  313 
diff.    fr.    scarlatina,    fr.    acute  tonsil- 
litis, 312;    fr.  acute   rheumatic  sore 
throat,  312,  324;    fr.  sore    throat   of 
scarlet  fever,  324 ;  fr.  acute  follicular 
pharyngitis.  339 
sthenic   pneumonia,    syn.    of  lobar  pneu- 
monia, 113 
tonsillitis,  362-367 

syn.,  362;   anat.,  path.,  etiol.,  symp., 

363:   diag.,  364;  prog.,  treat.,  366 
diff.    fr.    acute   sore    throat,    312;    fr. 
scarlatina,    fr.    diphtheria,    fr.    sup- 
purative tonsillitis,  fr.  syphilitic  sore 
throat,  364-366 
tubercular  phthisis,  diff.  fr.  lobular  pneu- 
monia, 127 
tubercular  sore  throat,  350-353 

anat.,  path.,  etiol.,  symp.,  350;   diag., 

351 ;   prog. ,  treat. ,  352 
diff.  fr.    rheumatic   sore    throat,  320; 
fr.  chronic  follicular  pharyngitis,  344; 
fr.  syphilitic  sore  throat,  351,  352,  355; 
fr.  scrofulous  sore  throat,  350,  351,  352 
tuberculosis  diff.  fr.  emphysema,  111 
Adams'  clamp,  596 

Adenoid  growths  in  the  vault  of  the  pharynx, 
syn.  of  hypertrophy  of  the  pharyn- 
geal tonsil,  613 
Adenomata,  467 


660 


INDEX. 


Adhesion  in  syphilitic  sore  throat,  355 

of  the  inner  surfaces  of  the  arytenoid 
cartilages,  diff.  fr.  bilateral  paraly- 
sis, 513 

Adirondacks  for  phthisis,  the,  175 

Adventitious  sounds,  48-54 

iEgophony,  55,  57 

Aerial  goitre,  syn.  of  tracheocele,  486 

Age  modifies  percussion  sounds,  27 

Aitken,  membranous  croup,  411 

Albolene  in  inhalations  or  sprays  for  throat  and 
nose,  95,  441,  530,  535,  538,  557,  568,  587 

Alcoholic  stimulation  in  bronchitis,  98;  in  pul- 
monary phthisis,  171 ;  in  acute  endo- 
carditis, 221 ;  in  chronic  endocar- 
ditis, 224;  in  angina  pectoris,  252; 
in  erysipelatous  sore  throat,  316;  in 
diphtheria,  335;  in  syphilitic  laryn- 
gitis, 448 

Algiers  for  phthisis,  176 

Allen,  Harrison,  inequality  of  the  choanse, 
309;  galvano-cautery,  544 

Allingham,  mouth  gag,  illus.,  419,  617 

Allison,  Scott,  stethogoniometer,  illus.,  18; 
differential  stethoscope,  illus.,  37 

Alps,  goitre  in  the,  629 

Ambidexterity  in  examination  of  the  larynx, 
285 

American  Journal  of  Medical  Sciences,  con- 
tagious pneumonia,  Wagner,  116; 
diphtheria,  Prudden,  329;  congenital 
syphilis,  John  N.  Mackenzie,  449; 
lupus,  G.  M.  Lefferts,  451 ;  laryngec- 
tomy, George  B.  Fowler,  483 
Laryngological  Association,  Transactions, 
Registers  of  male  and  female  voices, 
Thomas  R.  French,  298;  choanal  un- 
equal, Allen,  309;  acute  tubercular 
sore  throat,  Delavan,  352;  leucoplakia 
buccalis,  Ingals,  362;  chromic  acid 
in  trachoma,  Charles  E.  Sajous,  408 ; 
tubercular  laryngitis,  Jarvis,  441 ; 
feeding  in  laryngitis,  Beverly  Rob- 
inson, 443;  snare  forceps,  Jarvis, 
473 ;  thyrotomy,  Joseph  Leidy,  475 ; 
laryngotomy,  Cohen,  482;  chorea 
laryngis,  George  M.  Lefferts,  E. 
Holden,  501;  same,  F.  I.  Knight,  501. 
502;  falsetto  voice,  J.  C.  Mulhall, 
503;  laryngeal  vertigo,  F.  I.  Knight, 
504;  relation  of  hay  fever  and  condi- 
tions in  the  nasal  passages,  William 
H.  Daly,  553 ;  nasal  cancerous  tumors, 
R.  P.  Lincoln,  573;  deflection  of  tin' 
nasal  septum,  D.  Bryson  Delavan,  594; 
same,  D.  N.  Rankin,  605;  rhino- 
laryngitis,  Beverly  Robinson,  609; 
extirpation  of  nasal  tumors,  Lincoln, 
622 

Amphoric  cough,  59;  resonance  defined,  30; 
respiration,  41,  46,  47;  sound,  41; 
voice,  55,  57;   whisper,  58 

Amygdalitis,  syn.  of  acute  tonsillitis,  362 

Amyl  nitrite  in  chronic  endocarditis,  229 

Anaemia,  diff.  fr.  endocarditis,  226;  fr.  tuber- 
cular laryngitis,  437 


Anaemic,    haemic    or   organic    murmurs,    196, 

204;   diff.  fr.  atheroma,  256 
Anaesthesia   of   the   larynx,    499,    500;    etiol., 
symp.,   diag.,   prog.,   treat.,   499;   of 
the  pharynx,  etiol.,  prog.,  treat.,  388 
produced  generally,  495,  582,  606 
produced  in  tubercular  laryngitis,  442 
produced  locally,  74,  80,  266,  407,   409,   422, 
457,  484,  495,  544,  568,  597,  598,  425,  442 
Anaesthetics,  pigment,  655 
Anatomy  and  physiology  of  the  heart,  177-180 
Anchylosis  of  the  arytenoid   cartilages,   514, 

515;  diag.,  treat.,  515 
Anemone    pratensis.    unsatisfactory    in   per* 

tussis,  155 
Aneurism,  aortic  or  thoracic,  16,  256-266 

of  the  aorta,   diff.   fr.   acute  pleurisy,  70; 
fr.  solid  tumors,  262;   fr.  aortic  pul- 
sation, fr.  pulsating  empyema,    263; 
fr.  dilated  auricle,   fr.  consolidation 
of  the  lung,  264 ;   f r.  aneurism  of  the 
pulmonary  artery,  265 
of  the  arch  of  the  aorta,  257 
of  the  arteria  innominata,  265,  266 
of  the  ascending  aorta,  illus.,  209 
of  the  descending  aorta,  257 
of  the  heart,  etiol.,  diag.,  prog.,  treat.,  245 
of  the  pulmonary  artery,  264.  865 

diff.  fr.  aneurism  of  the  aorta,  265 
of  the  sinuses  of  Valsalva,  257 
Aneurismal  murmur,  diff.  fr.  mitral,  198 
Aneurismatiscope,  the,  261 
Angina  diphtheritica,  syn.  of  diphtheria,   328 
epiglottidea,  syn.  of  acute  laryngitis.  394 
laryngea,  syn.  of  acute  laryngitis,  394 
membranosa,  syn.  of  diphtheria,  328 
pectoris,  250-253 

etiol.,   250;    symp.,   diag.,   prog.,    251; 

treat. ,  252 
diff.   fr.  pseudo-angina,  fr.  intercostal 
neuralgia,    fr.     acute     pleurisy,   fr. 
myalgia,  251,  252 
Angiomata,    or   vascular   tumors,    illus.,    467, 
468 
of  the  nose,  syn.  of  vascular  nasal  tumors, 
570 
Annales    de    Gynecologie    et    d'Obstetrique, 
diphtheria,  Roux  and  Yersin,  336 
des  Maladies  de  TOreille,  fractures  of  the 
larynx,  Panas,  489 
Annual   of   the   Universal    Medical    Sciences, 
distoma     pulmonale,     151 ;    pseudo 
diphtheria,   Smith  and  Warner,  329 
diphtheria  infectious  through  cloth 
ing     or     furniture,     Grancher,    334 
spasm   of  the  glottis,  Lubet-Barbon 
496;   rhinitis,   Raulin,   532;   nasal  os 
seous    cysts,    Macdonald    quoted   by 
Charles    E.     Sajous,     570;     adenoid 
growths  in  deaf-mutes,  Wr6blewski, 
614 
Anomalous  heart  sounds,  205 
Anorexia  in  tubercular  laryngitis.  437 
Anosmia,  591,  592 

etiol.,  591;   symp.,  diag.,  prog.,  treat.,  592 
Anstie,  F.  E.,  value  of  sphygmograph,  211 


INDEX. 


661 


Antipneumotoxin  in  pneumonia,  blood  seram 

or,  123 
Antipyrine  in  whooping  cough,  155;    in  rheu- 
matic sore  throat,  317 
Antiseptic  gargles,  formulae  for,  647 
lozenges,  formulae  for,  648 
vapor  sprays,  formulae  for,  653 
and  stimulant  insufflations,  formulas  for, 

657 
pigments,  formula?  for,  656 
Antispasmodic    vapor     inhalations,    formula? 

for,  650 
Antrum,  empyema  of  the,  579-583 

of  Highmore,  ilfus.,  302,  579 
Aorta,  the,  179 

aneurism   of  the    (see  aortic   or  thoracic 

aneurism) 
aneurism  of  the  ascending,  209 
aneurism  of  the  descending,  257 
atheroma  of  the,  254-256 
coarctation  of  the,  266,  267 
rupture  of  the,  255 
Aortic  aneurism,  diff.  fr.  pulmonary  cancer, 
148 
area,  illus.,  198,  199 
endarteritis,  syn.  of  atheroma  of  the  aorta, 

254 
murmurs,  198-200 
obstruction,  illus.,  209,  225,  230 
or  thoracic  aneurism,  14,  256-266 

anat.,    path.,    etiol.,    256;    symp.,  258; 

diag. ,  262;  prog.,  treat.,  265 
diff.     fr.      chronic     endocarditis,    226, 
227;    fr.  eccentric  cardiac   hypertro- 
phy, 238;  fr.  solid  tumors,  fr.  aortic 
pulsation,  fr.  pulsating  empyema,  fr. 
dilatation  of  the  auricle,  fr.  aneurism 
of  the  pulmonary  artery,  fr.  consoli- 
dation of  the  lung,  262-265 
pulsation,  diff.  fr.  aneurism,  263 
regurgitant  murmurs,  200 
regurgitation,  illus.,  209,  225,  228,  230 
semilunar  valves,  178 
valves,  7;   disease  of,  256 
Aortitis,  254 

Apex -beat  of  the  heart,  10,  182,  184-185 
Apex,  pleurisy  of  the,  82 

Aphonia,  functional,   hysterical,   or  nervous, 
syn.    of    bilateral    paralysis    of   the 
lateral  crico-arytenoid  muscles,  508 
Aphonic  pectoriloquy,  58 

Aphthous  sore  throat,  syn.  of  simple  mem- 
branous sore  throat,  324 
Apneumatosis,   syn.   of   pulmonary   collapse, 

139 
Apoplexy,  pulmonary,  15,  137,  138 
Applicator,  chromic  acid,  409;   for  intubation 
tubes,  illus.,  420;   cotton,  568;   post- 
nasal snare,  623 
Arch  of  the  aorta,  aneurism  of  the,  257 
Arching  of  the  tongue  an  obstacle  to  laryn- 
goscopy, 290 
Archives  GSnerale  de  Medecine,  erysipelatous 
sore   throat,    Cornil,    314:  erysipela- 
tous laryngitis,  Cornil,  428 
Archives   of    Laryngology,  trachoma    of    the 


vocal  cords,  Carlo  Labus,  408;  lupus 
of  the  larynx,  F.  I.  Knight,  451 
Archives  of  Pediatrics,  influenza,  Charles  W. 

Earle,  520 
Area  of  cardiac  impulse,  185;  of  cardiac  dul- 
ness,  flatness,  189;  of  cardiac  sounds, 
191;    valvular,    197:    of    endocardial 
murmurs,  illus  ,  198 
Argand  lamp  for  laryngoscopy,  279,  281 
Arizona  for  phthisis,  175 
Arteria  innominata,  aneurism  of  the,  265 
Arterial  diseases,  cardiac  and,  212-268 
Artificial    light     to     illuminate    the    larynx, 

direct,  indirect,  275 
Ary-epiglottic  folds,  296 

muscles,  paralysis  of  the  thyro-epiglottic 
and,  505 
Aryteno-epiglottidean  folds,  296 
Arytenoid  cartilages,  illus.,  296 

cartilages,  anchylosis  of  the,  514,  515 
muscle,  paralysis  of  the,  511 
Asch,  Morris,  lupus  of  the  larynx,  451 
Aspiration  in  acute  pleurisy,  72;    in  subacute 
pleurisy,  73-75;    in  chronic  pleurisy, 
78;   in  abscess  of  the   lung,  131;  in 
pericarditis,  217 
Aspirator,  mode  of  using  the,  73-75 
Asthenia  in  diphtheria,  333;  in  acute  tubercu- 
lar sore  throat,  352 
Asthma,  102-105 

anat.,  path.,  102;  etiol.,  103;  symp.,  104; 

diag.,  prog.,  105;  treat.,  106 
diff.  fr.  bronchitis,  92;  fr.  capillary 
bronchitis,  fr.  spasmodic  laryngeal 
affections,  fr.  emphysema,  fr.  cardiac 
dyspnoea,  105;  fr.  stenosis  of  the 
larynx,  457;  fr.  hay  fever,  554 
Asthmatic  hay  fever,  554 

Astringent  and  stimulant  insufflations,  form- 
ulae for,  657 
and  stimulant  spray  inhalations,  formula? 

for,  652 
gargles,  formulas  for,  649 
lozenges,  formulas  for,  643 
pigments,  formulas  for,  656 
Asystolism,  241 

Atelectasis,  syn.  of  pulmonary  collapse,  139 
Atheroma  of  the  aorta,  254-256 

syn.,   anat.,   path.,  etiol.,   254;  symp., 

diag.,  255;    treat.,  256 
diff.    fr.    disease    of    the    valves,    fr. 
anaemic  murmurs,  256 
Atheromatous  degeneration  of  the  aorta,  syn. 

of  atheroma  of  the  aorta,  254 
Atomizer,  401,  402;  for  oil,  536 
Atrophic  follicular  pharyngitis,  343 
rhinitis,  528,  547-552 

anat.,   path.,  547;    etiol.,    symp.,   548; 

diag.,  prog.,  549;  treat.,  550 
diff.    fr.     lupus,   fr.    syphilis,    fr.  sup- 
puration,   fr.  rhinoliths,    fr.  foreign 
bodies,  549;    fr.  chronic  suppurative 
ethmoiditis,  586 
Atrophy  of  the  heart,  syn.  diag.,  242 

of  the  vocal  cords,  515 
Auricles  of  the  heart,  178 


662 


INDEX. 


Auricular  systole.  182;  illus..  201 

Auscultation.  9.  34-47:  mediate,  immediate. 
34:  rules  for.  38;  in  health,  39-41;  in 
disease.  41-47;  over  the  heart.  189;  in 
aneurism  of  the  aorta,  261 

Auscultatory  percussion.  32-33 

Austria,  rhinosclerma  in,  588 

Austrian  mountains  for  phthisis.  175 

Autumnal  catarrh,  syn.  of  hay  fever,  553 

Avenbrugger.  percussion.  21 

Avery,  laryngoscopy,  272 

Axillary  region,  4,  8 

Babbingtox.  laryngoscopy,  272 

Bacilli,  tubercle,  157;  transmitted  to  foetus, 
158;  staining,  164.  165;  in  endocardi- 
tis, 222:  in  lupus  of  the  larynx,  451 

Bacillus,  Klebs-Loffler,  diph.,  329 
mallei,  glanders,  589 
tuberculosis.  578 

Bacteria  in  pericarditis  purosa,  212;  in  ulcer- 
ative pericarditis,  222;  in  hypertro- 
phy of  the  tonsils,  370 

Balfour,  G.  W. .  quality  of  murmurs  of  the 
heart,  200;  heart  disease,  247;  brady- 
cardia. 250;  mode  of  administering 
chloroform  in  angina  pectoris,  252 

Barker,  Fordyce,  turpeth  mineral  in  croup,  417 

Barrel -shaped  chest,  12 

Base  of  heart,  to  find,  188 

Basedow's  disease,  syn.  of  exophthalmic 
goitre,  632 

Battery,  galvano-cautery,  345 

Baumes,  laryngoscopy,  272 

Bazin,  leucoplakia  buccalis,  360 

BelfieW,  W.  T. ,  guaiacol  in  phthisis.  173; 
iodine  trichloride  in  surgery.  441 

Bell  sound  in  percussion.  31 

Bellocq,  laryngoscopy,  272;  canula,  306 

Benign  growths  in  the  larynx,  illus.,  466-476 
synip.,466;  diag.,467;  prog. ,  treat..  4C9 
diff.  fr.  syphilis,  fr.  tubercular  laryn- 
gitis, fr.  lepra,  lupus,  outgrowths,  fr. 
eversion  of  the  ventricles,  fr.  malig- 
nant tumors,  467-469;  fr.  malignant 
tumors,  479,  573 

Bennatti,  laryngoscopy,  272 

Berberine,  identical  with  hydrastine,  95 

muriate    in    chronic    laryngitis,    407;    in 
rhino-pharyngitis,  610 

Berliner  klinische  Wochenschrift,  tubercles 
in  1  in  i  jr.  Yin -how.  107;  sound  in  em- 
physema. Gerhardt,  109;  pneumonia 
contagious.  Kuhn,  116;  blood  serum 
or  antipneumotoxin  in  pneumonia, 
Klemperer,  123;  dislocation  of  the 
larynx,  H.  Braun.490;  operations  on 
the  antrum.  Krause,  582 

Best,  J.  E..  furunculosis  of  the  nose,  559 

Biegauski,  pleurisy,  66 

Bilateral    paralysis   of  the  lateral   crico-ary- 
tenoid  muscles,  illus.,  508-510 
syn.,  etiol. ,   symp.,  508;   diag.,  treat., 
510 
paralysis  of  the  posterior  crico-arytenoid 
muscle,  illus.,  511-513 


Bilateral  paralysis  of  the  posterior  crico-ary- 
tenoid muscle,  anat.,  path.,  etiol., 
symp.,  512;  diag..  prog.,  treat.,  513 
diff.  fr.  adhesion  of  the  inner  surfaces 
of  the  arytenoid  cartilages,  fr. 
spasm,  513 

Bilious  pneumonia.  128,  129 

Bilocular  pleurisy,  diff.  fr.  other  forms.  83 

Birch-Hirschfeld.  F.  V. ,  bacilli  transmitted  to 
fcetus.  158 

Bird,  hydatid  cysts  of  the  lungs,  149 

Bizot,  aortitis,  254 

Black,  G.  V.,  cinnamon  water  antiseptic.  336 

Blake,  Clarence,  snare  for  polypi.  567 

Blanden,  deflection  of  the  nasa)  septum,  595 

Blood  serum  or  antipneumotoxin  in  pneu- 
monia. 123 

Blue  disease,  the,  syn.  of  morbus  cseruleus.  246 

Bocelli,  Guido,  distinction  between  serum  and 
pus.  77 

Boileau,  aortic  regurgitation,  illus.,  209 

Bokai,  retropharyngeal  abscess,  384 

Bollinger,  case  of  glanders  eleven  years,  590 

Bone  drill,  582 

Bony  tumors,  nasal,  571,  572 

Borgiotti.  case  of  oesophageal  spasm  five  hun- 
dred and  thirty-one  days.  638 

Boric  acid  in  cinnamon  water  highly  effective 
in  diphtheria,  336 

Bosworth,  tongue-depressor,  illus.,  271;  tuber- 
cular laryngitis,  436;  cancer  in  the 
larynx,  476;  chronic  rhinitis.  537.  545; 
mucous  polypi  in  asthma,  565; 
saws.  601 

Bougie,  oesophageal.  390;  olivary,  635 

Boundaries  of  the  heart,  188 

Bouveret,  L. .  pleurisy,  76;  tachycardia,  249 

Bowditch.  danger  in  washing  pleural  cavity,  78 

Boyle,  immediate  auscultation,  34 

Bozzini,  laryngoscopy,  272 

Bradycardia,  treat..  250 

Brainard,  bone  drill,  illus.,  582 

Braun,  H.,  dislocation  of  the  larynx,  490 

Bristle  extractor,  illus.,  642 

British  Medical  Journal,  cause  of  angina  pec- 
toris, Douglas  Powell.  250;  diph- 
theritic bacilli,  Armand  Ruffer,  329 

Broad  condylomata,  353 

Brodie,  mode  of  applying  mercury  to  infants, 
577 

Bronchial  cough,  59 
fremitus,  16 

glands  enlarged,  152,  153 
respiration,  41,  45 

tubes,  fremitus  in  dilatation  of  the,  15 
whisper,  normal,  exaggerated,  cavernous, 
58 

Bronchiectasis  or  bronchicatasis,  syn.  of  dila- 
tation of  the  bronchial  tubes,  100; 
syn.  of  fibroid  phthisis,  156 

Bronchitis.  89-100;  acute  and  subacute.  89, 
90;  chronic,  89,  90-95;  capillary,  95-98; 
plastic,  99,  100 
diff.  fr.  abscess  of  the  lung,  130:  fr. 
pulmonary  gangrene,  145;  fr.  trach- 
eitis, 461 


INDEX. 


663 


Broncho-cavernous  respiration,  46 

Bronchocele,  syn.  of  goitre,  629 

Bronchophony,  36;  normal,  55;  whispering,  58 

Broncho-pneumonia,  syn.  of  lobular  pneu- 
monia, 123 

Bronchorrhagia.  134 

Bronchorrhcea,  92 

Bronchotomy,  495 

Broncho-vesicular  or  harsh  respiration,  41,  44 

Brooklyn  Medical  Journal,  pneumonia  con- 
tagious. Hatheson,  116 

Brower,  Daniel  E.,  mode  of  ventilation  in 
diphtheria,  334;  exophthalmic  goitre, 
632 

Brown  induration,  symp. ,  diag. ,  treat.,  134 

Browne,  Lennox,  diphtheria,  328,  334,  336; 
acute  tubercular  sore  throat,  350,  351 ; 
hypertrophy  of  the  tonsils,  373; 
spasm  of  the  pharynx,  390;  definition 
of  croup.  411 ;  syphilitic  laryngitis, 
443,  448.  449 :  lupus  of  the  larynx,  453 ; 
lepra  of  the  larynx,  454;  endo-laryn- 
geal  cauterization  in  cancer,  opera- 
tion of  resection  of  the  larynx,  481 
Walton,  epistaxis,  562 
W.  N. ,  large  rhinolith,  604 

Bruit  de  diable.  syn.  of  venous  murmur,  207 
de  pot  fele,  syn.  of  cracked-pot  resonance, 
31 

Brans,  Paul,  pincette,  illus.  ,291;  infra-thyroid 
laryngotomy,  476 

Bulbar  paralysis,  progressive,  391 

Bulletin  de  la  Society  de  Chirurgie.  deflection 
of  the  nasal  septum,  Chassaignac,  595 
medicale  des  Vosges,  cause  of  angina  pec- 
toris, Liegeois,  250 

Burns  of  the  pharynx,  scalds  and,  392 

Burrs,  nasal.  546,  598 

Bursa  pharyngea,  illus. ,  309 

Cabot,  A.  T..  pleurotomy.  76;  drainage  tubes, 

illus..  79 
Calculus  of  the  tonsil,  syn.  of  concretions  of 

the  tonsils,  375 
California  for  bronchitis,  95;  for  phthisis.  175 
Calomel  in  lobular  pneumonia.  122:   in  acute 

sore  throat,  313 ;  in  diphtheria,  33S 
Camman,  stethoscope,  illus.,  32,  36 

and  Clark  instituted  auscultatory  percus- 
sion. 32 
Campbell,  see  Harries  and  Campbell 
Canadian    Practitioner,    siphon    drainage    in 

pleurisy.  Powell,  79 
Cancer  (see  also  malignant) 
Cancer,  diff.  fr.  leukoplakia  buccalis.  362 
of  the  larynx,  diff.  fr.  chronic  laryngitis. 
403.  404;  fr.  syphilitic  laryngitis.  447; 
fr.  lupus,  453 
of  the  pharynx,  anat. .  path.,   symp.,  386; 
diag.,    treat.,    387;    diff.    fr.    chronic 
rheumatic  sore  throat,  320;  fr.  syph- 
ilis, fr.  fibrous  tumors,  387 
of  the  tonsil,  380.  381 

diag.,  380;  prog.,  treat..  81 
diff.   fr.  tubercular   ulceration  of  the 
tonsils,    378;     fr.    hypertrophy,    fr. 


syphilitic   ulceration,    380,    381;    fr. 
rhinoliths,  605 
Cancer,  pulmonary,  70.  146.  148 
Cancerous    growths,    diff.    fr.    nasal    mucous 
polypi.  566;  fr.  nasal  bony  tumors,  572 
Capillary  bronchitis,  95-98 

anat.,  path.,  95;   etiol.,  symp.,  diag., 

96;  prog.,  treat.,  98 
diff.  fr.    phthisis,    98;   fr.    asthma,    97, 
105;  fr.  lobar  pneumonia,  fr.  lobular 
pneumonia,   fr.    pulmonary  oedema, 
97,  98 
Carbon  dioxide  in  asthma,  106 
Cardiac  and  arterial  diseases,  11,  183,  212-268 
aneurism,  245 
dilatation  syn.  of  dilatation  of  the  heart, 

239 
displacement,    diff.    fr.    hypertrophy    and 

dilatation  of  the  heart,  238 
dulness,  188-190 
hypertrophy,  14 
hypertrophy,  eccentric.  236 
hypertrophy,  simple,  234-236 
impulse,  185 
murmurs.  195-211 
origin  of  dropsy,  indicated,  11 
pulsation,  185,  187 
region,  form  of  the,  184 
resonance,  25 

sound,  modified  by  disease,  185 
Cardialgia,  247 
Cardiectasis,  syn.  of  dilatation  of  the  heart, 

239 
Cardio-pleuritic  friction  murmurs,  196 
Carious  teeth,  a  soil  for  leptothrix  buccalis, 

376 
Carroll,  stethometer,  illus.,  17 
Cartilages,  arytenoid,  296,  514;  of  Santorini,  of 
the  larynx,  of  Wrisberg,  296 ;  cricoid, 
tracheal,  299 
Cartilaginous  tumors,  illus.,  467 

diff.  fr.  nasal  mucous  polypi,  566;  fr. 
haematoma  of  the  nasal  septum,  602 
Cary,  Frank,  mode   of   feeding  after  intuba- 
tion, 421 
Caseous  pneumonia,  156 
Casselberry,  Wni.  E. ,  mode  of  feeding  after 

intubation,  421 
Catarrh,    epidemic,    519;     acute    nasal,    522; 

chronic,  527;  autumnal,  553 
Catarrhal  diathesis,  607 
fever,  epidemic,  519 
hay  fever,  554 
laryngitis,  illus.,  399 

diff.  fr.  diphtheria,  331;  fr.    croup,  413 
pneumonia,  syn.  of  lobular  pneumonia,  123 
sore  throat,  syn.  of  acute  sore  throat,  311 
stage  of  croup,  412 
Catarrhus  aestivus,  syn.  of  hay  fever,  553 
Caustics— pigments ;  stimulants  and,  656 
Cautery  electrodes,  346 

in  diseases  of  the  throat,  passim,  240-485; 
in    diseases     of    the    nose,    passim, 
530-637 
Cavernous  sound.  41 ;  respiration,  46;  whisper, 
58;   cough,  59 


664 


INDEX. 


Centralblatt  fiir  klinische  Medicin,    spasm  of 

the  fjesophagus,  Borgiotti,  638 
Cerebral  croup,  syn.  of  spasm  of  the  glottis, 

406 
Chancre  iu  the  throat,  353 
Chassaignac,    relation    of   generative   organs 
and    tonsils,   375;    deflection   of    the 
nasal  septum,  595;  retro-nasal  fibrous 
tumors,  621 
Cheesy  infiltration  of  the  lung,  156 
Chest,  dimensions  of  the,  3-8;    form  of  heal- 
thy,   9-12;  pigeon  breast,  10;  barrel- 
shaped,  12;  size  of  the,  17 
Cheyne-Stokes  respiration,  243 
Chiari  and  Rield,  lupus  of  the  larynx,  451 
Chicago  Medical  Journal  and  Examiner,  tym- 
panitic resonance  in  pleurisy,  Ingals, 
66 
Medical   Record,  resection   of  the  ribs  in 
pleurisy,  A.  B.  Strong,  78 
China,  distoma  pulmonale  in,  150 
Chloride  of  iron  in  erysipelatous  sore  throat, 

316 
Chlorine  inhalation  in  phthisis,  172 
Chloroform  for  angina  pectoris,  mode  of  ad- 
ministering, 252;  a  preferred  anaes- 
thetic for  children,  373.  495,  618;  for 
chronic   laryngitis,  407;  for  general 
anaesthesia,    422,    582;    preferred    to 
ether      in      tracheotomy,     425;     for 
cough,  501;  for  myasis  narium,  606 
Choanae.  the,  illus..  309 

Chondritis  and  perichpndritis  of  the  laryngeal 
cartilages,  433.  434 
etiol..  symp. ,  433;   diag. ,  prog.,  treat., 
434 
Chorditis  tuberosa,  syn.   of  trachoma  of  the 

vocal  cords,  408 
Chorea  laryngis,  501,  502 

anat.,  path.,  etiol.,  symp.,  501;    diag., 

prog.,  treat.,  502 
diff.  fr.  hysteria,  502 
Chromic  acid  applicator,  409 

acid  in  trachoma  of  the  vocal  cords,  409; 
effect  in  rhinitis  compared  with  that 
of  galvano-cautery.  537.  541 ;  in  hy- 
pertrophy of  the  pharyngeal  tonsil, 
616 
Chronic  abscess  of  the  nasal  septum,  diff.  fr. 
mucous  polypi,  565 
bronchitis,  14,  89,  90-95 

anat. ,  path. ,  90 ;  etiol. ,  symp. ,  91 ;  diag. , 
92;  prog.,  93;  treat.,  94 
catarrh,  syn.  of  chronic  rhinitis,  527;  syn. 

of  intumescent  rhinitis,  531 
catarrh    of   the    larynx,    syn.    of   chronic 

laryngitis,  398 
coryza,  syn.  of  chronic  rhinitis,  527 
endocarditis.  223-230 

etiol.,   symp.,   224;   diag.,  226;   prog., 

228;  treat.,  229 
diff.  fr.  functional  diseases  of  the  heart, 
fr.  pericarditis,  fr.  anaemia,  fr.   tho- 
racic  aneurism,  fr.    fatty    heart,  fr. 
congenital  deformity,  226.  •_'.'; 
follicular  glossitis,  347,  348 


Chronic     follicular    glossitis,    symp.,    diag., 
prog.,  treat.,  348 
diff.  fr.  rheumatic  sore  throat,  319 
follicular  pharyngitis,  illus.,  340-346 

syn.,    340;    anat.,    path.,    etiol.,    341; 

symp.,  342;  diag.,  prog.,  treat  ,  344 
diff.  fr.  chronic  rheumatic  sore  throat, 
319;  fr.  syphilis,   fr.  tubercular  sore 
throat,  344 
follicular   tonsillitis,  syn.  of  hypertrophy 

of  the  tonsils,  370 
inflammation  and  elongation  of  the  uvula, 
358-369 
diag.,  treat.,  359 
laryngitis,  illus.,  398-408 

syn.,  anat.,  path.,   398;   etiol.,  symp., 

399:  diag..  402;  prog.,  treat.,  404 
diff.  fr.  paralysis  of  the  vocal  cords,  fr. 
cedema  of  the  larynx,  fr.  tubercular 
or   syphilitic    laryngitis,    fr.  cancer, 
402-404 
myocarditis,  231 
oesophagitis,  633,  634 

etiol..  symp.,  diag.,  prog.,  treat.,  633 
pericarditis,  213 
pharyngitis,     syn.    of    chronic     follicular 

pharyngitis.  340 
pleurisy,  12,  76-82.  130 

anat.,   path.,  etiol.,  symp.,  76;  diag., 

prog.,  77;  treat.,  78 
diff.  fr.  pneumothorax,  fr.  hydro-pneu- 
mothorax,  88;  fr.  pulmonary  cancer, 
147 
pneumonia,    syn.    of   lobular  pneumonia, 
123.  128;  syn.  of  fibroid  phthisis,  167 
rheumatic  laryngitis,  syn.  of  chronic  rheu- 
matic sore  throat.  318 
rheumatic  sore  throat,  318-321 

syn.,  anat..   path.,   etiol.,   symp.,  318; 

diag.,  319;  prog.,  320;  treat.,  321 
diff.  fr.    chronic  follicular   tonsillitis, 
glossitis  or  pharyngitis,  fr.  tubercu- 
losis,  fr.    cancer,    fr.    neuralgia,   fr. 
tobacco  sore  throat,  319,  320 
rhinitis.  527-552 

syn..  527 
stenosis  of  the  larynx,  illus..  456-459 

anat..  path.,  etiol..   symp..   diag.,  456; 

prog.,  treat.,  457 
diff.  fr.  asthma,  fr.  foreign  bodies,  fr. 
compression,  fr.   tumors,   fr.  paraly- 
sis of  the  abductors,  457 
suppurative  ethmoiditis.  585-587 

etiol.,  symp.,  diag.,  585;   prog.,  treat., 

586 
diff.  fr.    mucous   polypi,    fr.    atrophic 
rhiuitis  with  redema,  fr.  suppuration 
of  the  antrum,  fr.  emphysema  of  the 
sphenoidal  and  frontal  sinuses,  585 
tonsillitis,  syn.  of  hypertrophy  of  the  ton- 
sils. 370 
tuberculosis,  156 

diff.  fr.  other  forms  of  phthisis,  166 
Ciniselli,  galvanic  puncture  in  thoracic  aneu- 
rism. 265 
Circumscribed  pleurisy,  82 


INDEX. 


665 


Circumscribed  pleurisy,  diff.  fr.  hydatid  cysts 
of  the  lungs,  150 

Cirrhosis  or  scirrhus  of  the  lungs,  syn.  of 
dilatation  of  the  bronchial  tubes, 
100;  syn.  of  fibroid  phthisis,  156,  167 

Clark,  see  Camman  and  Clark 

J.  E.,  immunity  to  tubercular  virus  se- 
cured, 172;  solution  of  iodine  for 
goitre,  631 

Clavicular  region,  4 

Clergyman's  sore  throat,  syn.  of  chronic  fol- 
licular pharyngitis,  340 

Climatic  treatment,  subacute  pleurisy,  75; 
bronchitis,  95,  100;  asthma,  106;  em- 
physema, 112;  lobula  rpneumonia, 
128;  pulmonary  phthisis,  174-178;  in- 
fluenza, 522;  hay  fever,  555,  558 

Clinical  Diagnosis,  Jasch,  bacilli  in  phthisis, 
164 

Closure  of  the  post-palatine  space  obstructing 
rhinoscopy  remedied,  305 

Cloves  in  laryngitis,  solution  of,  442 

Coarctation  of  the  aorta,  266,  267 
syn.,  266;  diag.,  treat.,  267 

Cocaine  as  an  anaesthetic,  74,  80,  266,  290, 370, 374, 

377,  407,  409,  422,  425,  457,  484,  491,  495, 

537,  544,  568,  597,  598,  603,  616,  617,  655 

as  a  sedative,  389,  501,  525,  527,  530,  538,  551, 

556,  584,  587,  651,  657 
caution  in  the  use  of,  352,  530,  556,  568 
not  to  be  used  as  a  sedative  in  acute  sore 
throat,  314 

Cog-wheel  respiration,  41,  43 

Cohen,  J.  Solis,  laryngeal  illumination,  282; 
laryngeal  examination,  illus.,  286; 
larynx  of  woman,  illus.,  295;  simple 
membranous  sore  throat,  327;  chronic 
follicular  pharyngitis,  illus.,  343; 
scrofulous  sore  throat,  348;  scalds 
and  burns  of  the  pharynx,  392;  hy- 
pertrophy of  the  larynx,  455;  benign 
laryngeal  tumors,  463;  malignant 
tumors  on  the  larynx,  476 ;  laryngec- 
tomy, 482;  nervous  cough,  499 ;  laryn- 
geal paralysis,  509;  spasm  of  the 
oesophagus,  637 

Cohnheim,  pulmonary  thrombosis,  138 

Coil  of  tubing  to  apply  cold  water  in  pneumo- 
nia, diphtheria,  croup,  122, 335,  369, 416 
(see  Leiter  coil) 

Cold  applications  in  pneumonia,  122;  in  cer- 
tain  diseases  of  the  throat,  307,  329, 
335,  361,  363,  369,  379,  386,  392,  408,  410, 
416,  633;  in  nose  bleeding,  552,  553 
(see  also  Ice) 

Collapse  of  the  jugular  veins,  207 
pulmonary,  139-142 

Colorado  for  asthma,  106;  for  phthisis,  175; 
rhinitis  in,  527 

Compendium  de  Chirurgie  Pratique,  deflection 
of  the  nasal  sectum.  Blanden,  596 

Complete  extirpation  of  the  larynx  described, 
482 

Compression  of  the  oesophagus,  637 

Concretions  in  the  tonsil,  syn.,  etiol.,  symp., 
prog.,  treat.,  375 


Condylomata,  syphilitic,  153,  468,  575 

Congenital  deformities   of  the  heart  diff.  fr. 
chronic  endocarditis,  226,  227 
deformity  of  the  nose,  treat.,  593 
murmurs,  204,  246 

syphilis  of  the  nose,  etiol.,  symp.,  diag., 
prog.,  treat.,  577 

Consolidation  of  the  lung,  diff.  fr.  hypertro- 
phy and  dilatation  of  the  heart,  237; 
fr.  aortic  aneurism.  264 

Convulsive  disorders  diff.  fr.  retropharyngeal 
.      abscess,  384,  385 

Corea,  distoma  pulmonale  in.  150 

Corniculum  laryngis,  syn.  of  cartilage  of  San- 
torini,  296 

Cornil,  erysipelatous  sore   throat,  314;    erysi- 
pelatous laryngitis,  428 

Corvisart,  syphilitic  disease  of  the  heart,  245 

Coryza,  acute,  522,  591;  chronic,  527;  syphi- 
litic, 567;  in  measles,  591 

Cotton  applicator,  illus.,  568 

Cough,  amphoric,  bronchial,  cavernous,  59; 
laryngeal,  59,  400;  in  hypertrophy  of 
the  tonsils,  371 ;  irritative,  nervous, 
498 

Cracked-pot  resonance,  28.  31 

Cramp  of  the  oesophagus,  syn.  of  spasm  of  the 
oesophagus,  637 

Creaking  or  crumpling  sounds,  53 

Creasote  for  pulmonary  phthisis,  173 

Crepitant  rales,  48,  51 
rale  redux,  118 

Crequy,  removal  of  foreign  bodies  in  the 
oesophagus,  642 

Crico-arytenoid  muscles,  paralysis  of  the, 
508-514 

Cricoid  cartilage,  illus.,  299 

Crico-thyroid  muscles,  paralysis  of  the,  506 

Croup,  membranous,  14,  411-426 
tent,  416 

Croupous  bronchitis,  syn.    of  plastic  bronchi- 
tis, 99 
pneumonia,  syn.  of  lobar  pneumonia,  113 

Crumpling  sounds,  creaking  or,  53 

Crushing  tumors  with  forceps,  474,  572 

Csokor,  transmission  of  bacilli  to  foetus,  158 

Cuneiform  cartilages,  syn.  of  cartilages  of 
Wrisberg,  296 

Curable  mitral  regurgitant  murmurs,  202 

Curschmann,  cause  of  asthma,  103 

Curtis,  H.  Holbrook,  chronic  rhinitis,  537; 
wash -bottle,  illus.,  586;  nasal  trephin- 
ing, 601;  vaporizer,  illus.,  612 

Curved  line  of  flatness  in  pleurisy,  illus.,  64,  65 

Cutting  forceps,  right  angle,  597 

operations  on  laryngeal  tumors,  474 

Cyanosis,  syn.  of  morbus  cssruleus,  246 

Cyclopedia  of  the  Diseases  of  Children,  pleu- 
rotomy,  A.  T.  Cabot,  78;  asthma 
among  Hebrews,  Saltmann,  103; 
double  pneumonia,  115 

Cyclopedia  of  Practical  Medicine,  rhinitis,  C. 
J.  D.  Williams,  525 

C3'nanche  laryngea,  syn.  of  acute  laryngitis,  394 
pharyngea,  syn.  of  acute  sore  throat,  311 
tonsillaris,  syn.  of  acute  tonsillitis,  362 


666 


INDEX. 


Cyrtometers,  17,  is 

Cystic  growths,  illus. ,  466;    retro-nasal,  556 
Cysts  of  the  lungs,  hydatid.  1-48-150 
Czermak,  laryngoscopy,  272 

Da  Costa,  J.  M.,  divisions  of  the  chest,  3;  tym- 
panitic resonance.  29,  30.  66;  pneumo- 
pericardium. 018;  irritable  heart  of 
soldiers.  049 

Dakota  for  phthisis,  175 

Daly,  William  H. .  hay  fever  related  to  condi- 
tions in  nasal  passages.  553 

Damoiseau,  pleuritic  symptoms.  64 

Danforth.  J.  N.,  mixed  sarcoma,  478 

Davidson,  atomizer,  illus.,  405,  406;  oil  atom- 
izer, illus..  536 

Deafness,  throat.  610-613 

De  Cerenville.  epilepsy  following  irritation 
of  pleural  surfaces,  78 

Deferred  expiration,  43 

Deflection  of  the  nasal  septum,  594-597 

anat.,  path.,  etiol.,  594;  syrup.,  diag., 
prog.,  treat.,  595 

Delafleld,  pneumonia  infective.  115 

Delavan,  D.  Bryson,  acute  tubercular  sore 
throat,  352;  hemorrhage  after  ton- 
sillotomy. 375;  leptothrix  buccalis. 
376;  electricity  in  rhinitis,  552;  em- 
pyema of  the  antrum,  579;  deflection 
of  the  nasal  septum,  594.  595 

Demulcents,  trochisci  or  lozenges,  formula?, 
648 

Dennison,  Charles,  binaural  stethoscope,  37 

Dental  Review,  cinnamon- water  antiseptic,  G. 
V.  Black,  336 

Derbyshire  neck,  syn.  of  goitre,  629 

Descending  aorta,  aneurism  of  the,  257,  258 

Des  Maladies  du  Sinus  Maxillaire,  multiple 
secretion  of  pus  in  the  antrum,  Gi- 
raldes,  579 

Deutsche  Chirurgie,  tracheotomy,  Max  Schiil- 
ler,  486 
Klinik,    benign    growths    in   the    larynx. 

Lewin.  465 
medicinische  Zeitung,  heredity  in  asthma, 

Lazarus,  100 
medicinische  Wochenschrift.  pneumonia 
contagious,  Mosler,  116;  transmission 
of  bacilli  to  foetus,  F.  v.  Birch- 
Hirschfeld,  158;  nasal  tuberculosis, 
F.  Halm.  578;  differentiation  of  nasal 
affections,  Max  Schaeffer,  586 
Medizinal-Zeitung.  transmission  of  bacilli 
to  foetus,  Csokor.  158 

Deutsches  Archiv  fin-  klinische  Medicin,  dan- 
ger from  heart  in  pleurisy,  Leichten- 
stern,  71 

Deviation  of  the  septum,  diff.  fr.  polypi,  565 

Diagnosis,  physical.  3  59 

Diaphragmatic  hernia,   diff.    fr.    pneumotho- 
rax, 88 
pleurisy.  71.  82 

Diastole  of  the  heart,  180 

Diastolic  murmurs.  203 

Dicrotism,  210 

Dictionnaire  Encyclopedic  des  Sciences  mgdi- 


cales,  inflammation  in  removal  of  na- 
sal tumors.  Oilier.  622 
Diffuse  abscess  of  the  larynx,  syn.  of  phleg- 
monous laryngitis.  427 
aneurism,  256 

pulmonary  hemorrhage,  syn.  of  pulmonary 
apoplexy.   137 
Dilatation  in  laryngeal  diseases,   449.  457.  459. 
17-.'.   188,515;    in  stricture  of  the  oeso- 
phagus, 635,  636 
of  the  aorta,  diff.  fr.    aortic  aneurism.  204 
of  the  bronchial  tubes,  15,  100-102 

syn.,  anat.,    path.,  etiol..  100;    symp., 

diag.,  101;   prog.,  treat.,  102 
diff.  fr.  phthisis.  101 ;  fr.  gangrene,  145 
of  the  heart.  238-242 

syn..  anat.,    path.,    etiol.  239:     symp., 

■.'in;    diag. ,  prog..  241 ;    treat.,  242 
diff.  fr.    pericarditis,    241 :  fr.  myocar- 
ditis. 232;    fr.  eccentric   cardiac   hy- 
pertrophy. 237 
hypertrophy  and.  236-239 
of  the  larynx.  457,  458 
Dilated  auricle,  diff.  fr.  aneurism  of  the  aorta, 

364 
Dilator,  cutting,  laryngeal,  458;    for  stricture 

of  the  oesophagus.  636 
Diminished  resonance,  55 
Diphtheria,  328-338 

syn..  anat.,  path.,  328:  etiol.,  329; 
symp.,  330;  diag.,  331;  prog.,  332; 
treat.,  &33 
diff.  f r.  sore  throat  of  scarlet  fever,  323 ; 
fr.  simple  catarrhal  or  rheumatic 
pharyngitis,  fr.  tonsillitis,  fr.  ery- 
sipelas, fr.  scarlatina,  fr.  simple 
membranous  sore  throat,  fr.  phleg- 
monous or  erysipelatous  sore  throat, 
fr.  phlegmonous  or  erysipelatous  sore 
throat,  331,  332;  fr.  hypertrophy  of 
the  tonsils,  332;  fr.  acute  tonsillitis, 
365;  fr.  croup,  415;  fr.  phlegmonous 
laryngitis.  427 
Diphtheritic  laryngitis,  455 

diff.  fr.  phlegmonous  laryngitis,  427 
Diphtheritis.  syn.  of  diphtheria.  328 
Diplococcus  pneumoniae  of  Fraenkel.  115 
Disease  of  the  aortic  valves,  diff.  fr.  atheroma, 

256 
Disinfection  in  diphtheria,  extreme,  334 
Dislocation  of  the  larynx,  490 

of  the  nasal  bones,  treat..  594 
Dissecting  aneurism,  256 

Disseminated  pneumonia,  syn.  of  lobular  pneu- 
monia, 123 
Distoma  pulmonale,  150.  151 

symp.,  diag.,  treat.,  151 
Divisions  of  the  chest,  illus.,  3-8 

supra-clavicular.  4 ;  clavicular.  4 ;  infra- 
clavicular. 4,  5;  mammary.  4,  5;  in- 
fra-mammary, 4,  6;  supra-sternal,  4, 
6;  sternal.  4,  6;  superior  sternal,  4, 
16;  inferior  sternal.  4,  7:  supra-scap- 
ular.  scapular,  inter-scapular,  7;  in- 
fra-scapular, 8;  axillary,  4,  8;  infra- 
axillary,  4,  8 


IXDEX. 


667 


Donaldson.  F.,  treatment   of  nasal  polypi,  566 
Douches,  nasal,  instruments,  551 

nasal,  formula?,  658 
Dover's  powder  in  acute  laryngitis.  396 
Drainage  tubes  for  chronic  pleurisy,  79-81 ;  in 
abscess  of  the  lung,  131 ;   for  empy- 
ema of  the  antrum,  583 
Drill,  bone,  582:  for  cutting  cartilage,  598 
Dropsy,  diseases  indicated  by.  11 
Dry  inhalations,  formulae.  654 

pleurisy,  61 

rales,  48 
Drzewiecki,  J. ,  pleurisy.  72 
Dulness.  25,  26,  28,  29;  triangle  of.  64;  cardiac, 

188-190 
Dupuytren,  retro-nasal  fibrous  tumors,  621 
Duration  of  sound,  23,  39 

Eaele,   Charles  Warrlsgton.    influenza.   520 

Eccentric  cardiac  hypertrophy,  syn.  of  hyper- 
trophy and  dilatation  of  the  heart. 
236 

Ecchondroma  and  exostosis  of  the  nasal  sep- 
tum, illus.,  597-601 
diag. ,  prog.,  treat.,  598 

Ecchondroses,  diff.  fr.  nasal  cartilaginous  tu- 
mors, 571 

Eclectic  inhaler,  649 

Ecrasement  in  hypertrophy  of  the  tonsils, 
mode  of.  373.  374 

Ecraseur,  galvano-cautery,  567,  569,  571,  573, 
622;  guarded  wheel.  474 

Edinburgh  Medical  Journal,  bradycardia.  Bal- 
four, 250 ;  anaesthesia  of  the  larynx, 
McBride,  499;  empyema  of  the  an- 
trum. McBride,  580;  large  rhinolith, 
W.  N.  Browne,  604 

Egypt  for  phthisis.  176:  nasal  syphilis  in,  574 

Electric  lamp  for  transillumination,  581 
light  for  laryngeal  illumination,  281 

Electricity  in  rhinitis.  552 

Electrodes,  cautery.  346;  laryngeal,  509,  511 

Electrolysis,  372.  601 :  method  of.  in  retronasal 
tumors  and  goitre,  622,  631 ;  for  stric- 
ture of  the  oesophagus,  637 

Ellis,  curved  line  of  flatness  in  pleurisy,  illus., 
64,  65 

Elongation  of  the  uvula,  chronic  inflamma- 
tion and,  358 

Elongated  uvula,  an  obstruction  to  laryn- 
goscopy, 289;  remedied,  305 

Emballometer,  33 

Embolism,  pulmonary  thrombosis  and,  138, 
139 

Emphysema,  subcutaneous,  11;  pulmonary, 
107-112;  atrophous,  109 

Empyema,  chronic  pleurisy  or,  61,  76-82 
of  the  antrum,  illus.,  579-584 

etiol.,   579:   symp.,   diag.,  580;    prog., 

treat.,  582 
diff.  fr.  empyema  of  the  frontal  sinus, 
fr.  suppuration  of  the  anterior  eth- 
moid cells,  fr.  polypus,  fr.  oza?na,  fr. 
foreign  bodies,  fr.  syphilis,  fr.  caries, 
fr.  disease  of  the  sphenoidal  sinus, 
580,  581 


Empyema  of  the  frontal  sinus,  diff.  fr.  empy- 
ema of  the  antrum,  581 
of  the  sphenoidal  sinuses,  583 
symp.,  treat.,  583 

diff.  f r.  empyema  of  the  antrum,  581 
Encephaloid  cancer  of  the  larynx,  476 
Endocardial  murmurs.  195.  196,  198 
Endocarditis,  acute.  219-222 
ulcerative,  222,  223 
chronic,  223-230 
Endocardium,  the,  178 
England,  goitre  in,  629 
Engorgement,  in  lobular  pneumonia.  113 
Enlarged  bronchial  glands,  152,  153 

anat.,  path,,  etiol.,  symp  ,  152;   diag., 

prog.,  treat..  153 
diff.  fr.  phthisis,  153 
glands  at  the  base  of  the  tongue,  diff.  fr, 

chronic  rheumatic  sore  throat,  319 
tonsils,  an  obstacle  to  laryngoscopy,  290 
Enlargement  of  the  heart,  syn.  of  simple  car- 
diac hypertrophy,  234 
or  bulging  of  the  precordial  region,  184 
Epidemic  catarrh,  syn.  of  influenza,  519 
catarrhal  fever,  syn.  of  influenza,  519 
Epigastric  pulsation.  187 

Epiglottis,  large  or  pendent,  obstructs  laryn- 
goscopy, 291 ;  illus. ,  294,  295 
ulceration  of  the,  395 
Epistaxis,  559-563 

syn.,  anat.,   path.,   etiol.,   symp.,  559; 

diag.,  prog.,  treat.,  560 
diff.  fr.  pulmonary  hemorrhage.  136 
Epithelioma,    361.   480;    diff.    fr.  lupus  of  the 

nares.  588;  fr.  rhinoscleroma,  589 
Erichsen,  nasal  syphilis.  577 
Erysipelatous  laryngitis.  428,  429 

etiol.,  symp.,  diag.,  prog.,  428;  treat., 
429 
sore  throat.  314-316 

etiol..  symp.,  diag.,  prog.,  treat.,  315 
diff.  fr.  diphtheria,  332 
Erythematous  sore  throat,  syn.  of  acute  sore 

throat.  311 
Ether  for  general  anaesthesia,  582,  618 
Ethmoiditis.  chronic  suppurative,  585-587 
Eustachian  orifice,  308 

Eversion  of  the  ventricle  of  Morgagni.  diag., 
treat,,  483 
of  the  ventricle  of  the  larynx,    diff.   fr. 
benign  tumors.  469 
Evulsion  of  nasal  mucous  polypi,  566 

of  tumors,  in  the  larynx.  473 
Exaggerated  bronchial  whisper,  58 
pulmonary  resonance.  28 
respiration,  42 
Examination  of  the  chest,  physical,  3-59;  of 
the  fauces.  271-310 
of  the  heart,  physical.  183-194 
of  the  trachea,  illus..  300 
Exocardial  friction  sounds  or  murmurs,  195 
Exophthalmic  goitre,  632 

syn.,  632 
Exostosis  of  the  nasal  septum,  ecchondroma 

and.  597-601 
Exostoses,  diff.  fr.  nasal  cartilaginous  tumors, 


668 


INDEX. 


571 :  fr.  bony  tumors,  GTS;  fr.  foreign 
bodies,  603 
Expiratory  power  greater  than  inspiratory,  20 
Extirpation  of  the  larynx,  partial,  complete, 

481,  482 
Extractor,  for  intubation,  420;  bristle,  642 
Exudative   bronchitis,    syn.    of   plastic   bron- 
chitis. 99 
laryngitis,  syn.  of  membranous  croup,  411 
stage  of  croup.  412 

Fagge,  Hilton,  surgery  in  croup,  415 

Fahnestock,  tousillitome,  illus..  372 

False  croup,  syn.  of  spasm  of  the  glottis,  496 

Falsetto  voice,  503,  504 

Faradism  or  faradization.  511,  513,  514,  640 

Fasciculated  sarcomata.  407 

Fatty  heart.  242-2-14 

etiol..  symp.,  242:  diag.  prog,  treat..  244 
cliff,    fr.  chronic   endocarditis,  226,  227; 
fr.  chronic  myocarditis,  232 
Fauces,  diseases  of  the,  311-381 
examination  of  the,  271-310 
Fauvel.  malignant  tumors  in  the  larynx,  476 
Feeble  respiration,  42 
Fetid  form  of  tracheitis.  461,  462 
Fibrinous    bronchitis,    syn.    of   plastic    bron- 
chitis, 99 
Fibro-cellular  tumors,    in  the  larynx,   illus., 

466 
Fibroid    degeneration    of   the   lungs,   syn.   of 
fibroid  phthisis,  156,  167 
disease  of  the  heart,  syn.  of  chronic  myo- 
carditis, 231 
disease  of  the  lungs,  cliff,  fr.  emphysema, 

111 
phthisis,  156,  167-169 

syn..  156,  167;   anat.,  path.,  167;   etiol., 

syrup.,  168;    prog.,  169;    treat.,  170 
diff.  fr.  other  forms.  166,  167 
phthisis,  syn.  of  dilatation  of  the  bronchial 

tubes.   100 
tumors,  diff.  fr.  adenoid  growths.  616 
Fibroma  of  laryngo-pharynx,  illus..  386 

of  the  vocal  cords,  illus.,  466,  467 
Fibromata  of  the  nares,  syn.  of  nasal  fibrous 

polypi.  569 
Fibro-mueous  tumors,  retro-nasal.  024.  (125 

diff.  fr.  nasal  fibromata.  621 
Fibrosis,  syn.  of  fibroid  phthisis,  167 
Fibrous    growths,     diff.     fr.     nasal    mucous 
polypi.  566 
polypi,  nasal,  569 
tumors  of  the  naso-pharyux.  620-624 

diff.  fr.  cancer  of  the  pharynx,  387;  fr. 

retro-nasal  fibro-mucous  tumors,  624 

Filer's   phthisis,    syn.    of    dilatation    of    the 

bronchial  tubes,  100 
First  stage  of  lobar  pneumonia.  117:  of  peri- 
carditis. 213:  of  phthisis,  161-104 
Fissures,  pulmonary,  8 
Flat  chest,  illus,.  12 

nasal  probe,  illus..  537 
Flatness,  hepatic,  cardiac.  85,  26 

diff.  fr.  dulness,  29 
Flexible  oesophageal  forceps,  illus.,  641 


Flint,  Austin,  cyrtometer,  illus. ,  17,  18;  ham- 
mer and  pleximeter,  illus.,  21;  per- 
cussion. 25.  96,  2S;  tympanitic  reso- 
nance, 66;  pulmonary  gangrene,  141; 
pulmonary  phthisis,  102 
Florida  for  phthisis.  175 
Fluctuation    of   fluid    in    the    pleural  cavity, 

signs  of,  16 
Follicular  disease  of  the  naso-pharynx,   syn. 
of  rhino-pharyngitis,  607 
glossitis,  acute,  chronic,  347,  348 
pharyngitis,    acute,  339,  340;  chronic,  340- 
340 
Fontaine,  citric  acid  in  diphtheria.  335 
Force  of  the  heart,  increased,  diminished,  186, 

187 
Forceps,  tonsil,  373:  laryngeal.  471;  tube, 
472;  punch,  485;  nasal  dressing,  576; 
septum.  596;  right  angle  cutting,  597; 
removing  pharyngeal  gland  with, 
618-620;  flexible  oesophageal,  641 
Foreign  bodies  in  the  larynx,  490^192 

symp..  490;    diag..  prog.,  treat.,  491 
diff.  fr.  abscess,  384,  385;  fr.  acute  lar- 
yngitis. 396;    fr.  phlegmonous  laryn- 
gitis, 428;    fr.  stenosis  of  the  larynx, 
457 
bodies  in  the  nose,  603,  604 

symp.,  diag.,  603;  prog.,  treat.,  604 
diff.  fr.  atrophic  rhinitis,  549;  fr.  em- 
pyema, 581 ;  fr.  nasal  mucous  polypi, 
565;  fr.  nasal  malignant  tumors,  573; 
fr.  exostosis,  fr.  rhinoliths,  fr.  sim- 
ple catarrh,  fr.  polypi,  603 
bodies  in  the  oesophagus,  640-642 

symp.,    640;    diag.,   prog.,  641;   treat., 

6 12 
diff.  fr.  stricture  of  the  oesophagus,  635 
fr.  globus  hystericus,  fr.  paraesthesia, 
641 
bodies  in  the  pharynx,  382,  383 

symp.,  diag.,  prog.,  treat.,  383 
bodies  in  the  trachea,  492-495 

symp.,  492;  diag.,  493;  prog.,  treat.,  494 
Formula  for  focal  distance  of  reflector,  276 
Formula?  for  prescriptions,  645-658 
Fornix  pharyngis,   syn.  of  vault  of  the  phar- 
ynx, 309 
Fort,    A.,    electrolysis   for    stricture    of    the 

oesophagus.  637 
Fossa  innominata.  297 

of  Rosenmueller,  illus.,  309 
Foster,  illustrations  of  the  action  of  the  heart, 

208,  210 
Fowler,  George  B.,  laryngectomy.  483 
Fox.  Higston,  acute  tonsillitis.  363 
Fracture  of  the  larynx,  489,  490 

anat.,  path.,  etiol.,  symp.,  diag..  prog., 
treat.,  489 
Fractures  of  the  nose,  593,  594 

symp. ,  diag. .  prog. ,  593 :  treat. ,  594 
Fraenkel.  diplococcus  pneumoniae.  115:    stain- 
ing bacilli.  165;  illuminator, 279,  280; 
rhinoscope.  illus..  303:   cause  of  in- 
fantile coryza.  522 
Fraentzel.  resonance  in  pleurisy,  66 


INDEX. 


669 


Frasnum  obstructs  laryngoscopy,  a  short,  290 

France  for  phthisis,  175;  goitre  in,  639 

Frank,  aortitis,  254 

Fremitus,  normal  vocal,  15;  friction,  bron- 
chial or  rhonchial,  16 

French,  Thomas  R.,  registers  of  male  and 
female  voice,  298 

Friction  fremitus,  16 

sounds   or    murmurs,    48,    51,   52,  53;    ex- 
ocardial,    pericardial,    cardiac,    195; 
endocardial     pleuritic,    cardio-pleu- 
ritic,  196 
treatment  in  laryngeal  tumors,  472 

Friedlander,  diplococcus  pneumoniae,  micro- 
coccus, 115 

Frog  face,  620 

Frontal  sinus,  inflammation  of  the,  584,  585 

Fuming  inhalations,  formulae,  654,  655 

Functional  aphonia,  syn.  of  bilateral  paralysis 
of   the  lateral  crico-arytenoid  mus- 
cles, 508 
disease    of    the     heart,    neurotic    or, 
247-249 

Furunculosis  of  the  nose,  558,  559;  treat.,  558 

Fiitterer,  L.  G.,  treatment  of  chronic  pleurisy, 
78 

Gags,  419,  618 

Gairdner,  diagram  of  physiological  action  of 
the  neart,  181 

Galvano-cautery  in  various  diseases  of  the 
throat  and  the  nose,  266,  340,  346,  348, 
367,  372.  373,  374,  380,  386,  410,  453,  470, 
501,  537,  538,  539,  544,  563,  568,  569,  570, 
571,  576,  578,  586,  588,  617,  622 
compared  with  chromic  acid,  537 
ecraseur,  573 

handle  with  ecraseur,  illus.,  567 
snare,  illus.,  623,  624 

Gangrene,  amphoric  resonance  in,  31 ;  in  lobar 
pneumonia,  115;    pulmonary,  144,  145 

Garcia,  Manuel,  laryngoscopy,  272 

Gargles,  formulas,  647 

Garland,  G.  M.,  curved  line  of  flatness  in 
pleurisy,  illus.,  64 

Gazette  des  Hopitaux,  sterilized  air  in  pneumo- 
thorax, Potain,  88;  potassium  iodide 
for  angina  pectoris,  Huchard,  253 ; 
removal  of  foreign  bodies  with  skein 
of  thread,  Crequy,  642 

Gazette  Hebdomadaire,  fracture  of  the  larynx, 
Henoque,  489 

Gee,  cyrtometer,  17;  tympanitic  resonance,  30 

Generative  organs  to  tonsils,  relation  of,  375 

Georgia  mountains  for  phthisis,  175 

Gerhardt,  pulmonary  emphysema,  109 

Germain  See,  lactose  diuretic,  230 

German  mountains  for  phthisis,  175 

student's  lamp  for  laryngeal  illumination, 
279,  281 

Germany  for  phthisis,  175 ;  rhinoscleroma  in, 
588 

Gibb,  erysipelatous  laryngitis,  429 

Gibbes,  Heneage,  bacilli,  illus.  (colored 
plate),  165;  secured  immunity  to  tu- 
bercular virus,  172 


Giraldes,  multiple  secretions  of  pus  in  the 
antrum,  579 

Glanders,  589,  590 

anat.,  path.,  etiol.,   symp.,  589;  diag. , 

prog.,  treat.,  590 
diff.   fr.   rheumatism,   fr.   pyaemia,  fr. 
typhoid  fever,  fr.  syphilis,   fr.  scrof- 
ulous eruptions,  590 

Glands,  enlarged  bronchial,    152,  153 
enlarged  at  base  of  tongue,  319,  389 

Gleitsmann,  tubercular  sore  throat,  352 

Globe  nebulizer,  illus.,  174 

Globus  hystericus,  500 

diff.    fr.    foreign   bodies   in   the   ceso-- 
phagus,  641 

Glossitis,  acute  follicular,  347 
chronic  follicular,  347,  348 

Glottis,  298 

spasm  of  the,  496,  497 

Goitre,  629-631 

syn.,  anat.,   path.,  etiol.,  629;   symp., 

diag.,  prog.,  treat.,  630 
diff.    fr.   exophthalmic  goitre,  fr.  ma- 
lignant tumors,  630 
aerial,  486 
exophthalmic,  632 

Gold  and  sodium  chloride  for  immunity  to 
tubercular  virus,  172;  for  syphilitic 
laryngitis,  448 

Gottstein,  malignant  tumors  in  the  larynx, 
476;  wool  tampons,  552 

Gouty  affections  diff.  fr.  chronic  rheumatic 
sore  throat,  319 

Grancher,  diphtheria  propagated  by  infected, 
clothing  or  furniture,  334      , 

Granular  sore  throat,  syn.  of  chronic  follicu- 
lar pharyngitis,  340 

Graves'  disease,  syn.  of  exophthalmic  goitre, 
632 

Gray  hepatization,  113,  114;  illus.,  117 

Great  Lakes,  rhinitis  near  the,  527 

Grippe,  syn.  of  influenza,  519 

Gross,  S.  D.,  foreign  bodies,  492,  494;  instru- 
ments for  removing  foreign  bodies, 
from  cavities  of  nose  and  ears,  illus. , 
604 

Guaiacol,  for  phthisis,  173 

Guaiacum  for  acute  tonsillitis,  366;  unsatisfac*. 
tory  in  phlegmonous  tonsillitis,  369 

Gueneau,  Noel,  diaphragmatic  pleurisy,  82 

Guido  Boeelli,  pus  diff.  fr.  serum,  77 

Guillotines  for  throat,  473 

Gumma,  353,  354 

Gurgles,  48,  52   . 

Gussenbauer,  artificial  larynx,  482,  483 

Guttmann,  tympanitic  resonance,  30 

Hack,  hay  fever,  related  to  conditions  in 
nasal  passages,  553 

Haamadynamometer,  19 

Haematemesis  diff.  fr.  haemoptysis,  135 

Haamatoma  of  the  nasal  septum,  etiol. ,  symp. , 
diag.,  prog.,  treat.,  602 
diff.  fr.  mucous  polypi,   fr.   cartilagi- 
nous tumors,  fr.  hypertrophy  of  the 
turbinated  body,  fr.  ecchondroma,  602 


670 


INDEX. 


Haemic  murmurs.  2''J 
Haemoptysis.  134.  135,  859 

diff.    fr.    baematemesis,  135;   fr.   epis- 

taxis.  fr.  lit- morrhage  of  the  gums  or 

the  pharynx,  136 

Hemostatics,  spray  inhalations,  formulae,  663 

Hahn.  F. .  nasal  tuberculosis.  578 

Haines.  W.  S. .  iodine  trichloride  in  tubercular 

laryngitis.  441 
Hairy  heart.  812 

Hamilton,     milk     spots.     212;    pneumoperi- 
cardium. 218;  acute  endocarditis.  219, 
820;  myocarditis,  231 
Hammer  for  percussion.  21 
Hammond,  haemadynamometer.  illus. .  19;  ex- 
piratory force  greater  than  inspira- 
tory. 80 
Harkin.  epistaxis.  561 
Harries  and  Campbell,  etiology  of  lupus  of 

the  larynx.  452 
Harsh  respiration,    syn.  of  broncho-vesicular 

or  rude  respiration.  44 
Hay  asthma,  syn.  of  hay  fever.  553 
fever.  553  "   - 

syn..    anat..    path.,  etiol..  553:  symp.. 

diag. .  554:  prog.,  treat..  555 
diff.  fr.  acute  rhinitis.  524:   fr.  simple 
chronic  rhinitis,  529 ;  fr.  simple  acute 
rhinitis,   fr.    spasmodic  asthma.  554. 
555 
Hayden,  illustration  of  motion  of  the  heart, 

209.   810 
Head,  sections  of,  302.  541.  579.  584 

for  laiyngoscopy,  good  and  poor  positions 

of,  384,  885 
lower  than  the  body  in  taking  food  in  cer- 
tain throat  diseases.  442.  506 
Heart,  the.  177-211 

aneurism  of  the.  245 

apex  beat  of  the.  10.  180,  182.  1-4 

atrophy  of  the.  242 

congenital  deformity  of  the.  227 

diastole  of  the,  180 

dilatation  of  the.  839-242 

failure  in  atheroma  of  the  aorta.  255 

fatty.  242  244  :  defeneration,  infiltration,  242 

force  of  the.  modified.  184.  186,  187 

hairy.  812 

neoplasms  of  the.  240 

neurotic    or    functional    disease    of     the, 

247-249 
physical  examination  of  the.  1N3-194 
physiological  action  of  the.  180-183 
rupture  of  the.  245 
sounds,  how  caused.  190.  191 :  modified  by 

disease.  191-194:  anomalous 
syphilis  of  the.  245 
systole  of  the.  180 
to  find  the  limits  of  the.  188 
tumors  of  the.  246 
valvular  disease  of  the.  223-230 
Heath.  Christopher,  empyema  of  the  antrum. 

588 
Helcosis   laryngis.  syn.  of   tubercular   laryn- 
gitis. 434 
Hemiplegia  causes  exaggerated  respiration.  42 


Hemming.  Hugh,  syrup  of  chloral  in  diph- 
theria. 336 

Hemorrhage,  pulmonary.  134-136:  after  ab- 
scission of  the  uvula,  359 ;  after  ton- 
sil lotomy.  374 

Hemorrhagia  narium,  syn.  of  epistaxis.  559 

Hemorrhagic    infarctus.    syn.    of    pulmonary 
apoplexy,  137 
pleurisy,  61 

Henoque.  fracture  of  the  larynx,  489 

Henrotin.  gag.  illus.,  419,  618 

Hepatic  duluess.  flatness,  25,  26 
pulsation,  187 

Hepatization,  red.  yellow,  gray,  113,  114 

Heredity  of  phthisis,  158 

Hernia,  diaphragmatic,  88 

Herpetic  sore  throat,  syn.  of  simple  membra- 
nous sore  throat.  324 
ulceration.  395 

Herynge  (see  Krause  and   Herynge) 

Hilton,  sacculus  laryngis.  297 

Himalayas,  goitre  in  the.  629 

Hippocrates  acquainted  with  suecussion,  20; 
percussion,  21 

Holden.  E. .  chorea  laryngis,  501 

Home  and  its  comforts  best  for  advanced 
cases  of  phthisis.  176 

Hooper,  F.  H. ,  operating  on  benign  tumors  in 
the  larynx.  473 

Hopmann,  nasal  papillary  tumors,  569 

Hospital  sore  throat,  syn.  of  chronic  follicular 
pharyngitis.  340 

Hot  applications  in  pneumonia,  122;  in  diph- 
theria. 335  :  in  phlegmonous  tonsillitis, 
369:  in  croup.  410:    in  tracheitis,  461 

Hotz.  F.  C,  throat  deafness.  611 

Huber,  myocarditis.  231 

Huchard.  free  protracted  use  of  potassium 
iodide  to  cure  angina  pectoris.  253 

Hungary,  rhinoscleroma  in.  588 

Hunter.  John,  empyema  of  the  antrum,  579, 
582 

Hutchinson,  spirometer.  18 

Hydatid  cysts  of  the  lungs,  148-150 

anat..  path.,  etiol.,  148;    symp.,  diag., 

149:  treat..  150 
diff.  fr.  phthisis.  149;  fr.  circumscribed 
pleurisy.  150 

Hyde.  J.  Nevins.  treatment  of  lepra  of  larynx, 
455 

Hydrastine  identical  with  berberine.  95 
for  chronic  follicular  pharyngitis,  344 

Hydro-pericardium  or  pericardial  effusion,  15, 
218,  219 
anat.,  path.,  etiol.,  symp..  diag.,  218; 

prog.,  treat..  219 
diff.  fr.  hypertrophy  and  dilatation  of 
the  heart.  238 

Hydrothorax,  13.  15.  84 

etiol..  symp.,  diag..  prog.,  treat.,  84 
diff.   fr.    pneumonia,   120;    fr.   pulmo- 
nary collapse.  143 

Hyperaemia,  pulmonary.  132-134 

Hyperesthesia  of  the  larynx,  82.  500.  501 

anat..  path.,  etiol..  symp..  diag.,  500; 
prog.,  treat.,  501 


INDEX. 


671 


Hyperesthesia  of  the  pharynx,  388,  389 
Hypersarcosis   cordis,  syn.  of  simple  cardiac 

hypertrophy,  234 
Hypertrophic  rhinitis,  illus.,  528,  540-547 

anat.,  path.,  etiol.,  symp. ,  540;    diag., 

542;  prog.,  treat.,  543 
diff.  fr.  intumescent  rhinitis,  534,  542; 
f r.  syphilis,  f r.  nasal  mucous  polypi, 
542,  543 
Hypertrophy,  simple  cardiac,  14,  234-236 

and  dilatation  of  the  heart,  illus.,  211,  236- 
239 
syn.,  symp.,  236;   diag.,  prog.,  treat,, 

239 
diff.   fr.  retraction  or  consolidation  of 
the  lung,    fr.  cardiac  dilatation,  fr. 
pericardial  effusion,   fr.  cardiac  dis- 
placement,   fr.    thoracic    aneurism, 
237-239 
of  the  larynx,  455 
of  the  liver  diff.  fr.  pleurisy,  70 
of  Luschka's  tonsil,  syn.  of  hypertrophy 

of  the  pharyngeal  tonsil,  613 
of  the  pharyngeal  tonsil,  illus. ,  613-620 
syn.,  anat.,  path., 613;  etiol.,  symp. ,614; 

diag.,  prog.,  treat.,  616 
diff.  fr.  nasal  mucous  polypi,  fr.  fibroid 
tumors,  616;  fr.  fibromata,  621 
of  the  spleen  or  of  the  liver,  diff.  fr.  pleu- 
risy, 70 
of  the  tonsils,  370-375 

syn.,  etiol.,  symp.,   370;   diag.,  prog., 

treat.,  371 
diff.  fr.  diphtheria,  332;  fr.  cancer,  380, 
381 
of  the  turbinated  body.  diff.  f r.  ha?rnatoma 
of  the  nasal  septum,  602 
Hypodermic  syringe,  illus.,  568 
Hypostatic  congestion,  133 
Hysteria,  diff.  fr.  chorea  laryngis,  502 
Hysterical  aphonia,  syn.  of  bilateral  paralysis 
of  the  lateral   crico-arytenoid  mus- 
cles, 508 
Hysterical  or  pseudo  angina  pectoris,  diff.  fr. 
angina  pectoris,  251 

Ice  in  diphtheria  and  other  diseases  of  the 
throat,  334,  367,  369,  416,  428,  633 

Ichthyosis  linguae,  syn.  of  leucoplakia  bucca- 
lis,  360 

Illumination  of  the  throat,  275-384 

Immediate  auscultation,  34 
percussion,  21 

Immunity  to  tubercular  virus,  how  secured,  172 

Incipient  hypertrophy  due  to  Bright's  disease, 
illus.,  210 

Incompetency  of  heart  valves  produced,  224 

Increased  vocal  resonance,  56 

India,  myasis  narium  in. '605 

Induration  of  the  lungs,  syn.  of  fibroid  phthi- 
sis, 167 

Infants,  syphilitic  sore  throat  in,  356;  syphili- 
tic laryngitis  in,  449;  acute  rhinitis 
in,  526;  syphilis  of  the  nose  in,  577 

Infectious  endocarditis,  syn.  of  acute  endocar- 
ditis, 219 


Inferior  costal  breathing,  11 
meatus,  illus.,  809 
sternal  region,  4,  6 
turbinated  bodies,  illus.  ,308 
Inflammation  of  the  antrum  or  frontal  sinuses 
diff.  fr.  acute  rhinitis,  524 
of  the  frontal  sinuses,  illus. ,  584,  585 

symp.,  treat.,  584 
of  the  larynx,  syn.  of  acute  laryngitis,  394 
of  the  lungs,  popular  name  for  pneumonia, 

113 
of  the  uvula,  acute,  chronic,  358-360 
Influenza,  519-522 

syn.,  anat.,  path.,    etiol.,   symp.,   519; 

diag.,  520;  prog.,  treat.,  521 
diff.    fr.    rhinitis,  fr.  inflammation  of 
the  larnyx,  521 
Infra-axillary  region,  4,  8 
Infra-clavicular  region,  4,  5 
Infra-glottic    dropsy,  syn.    of   oedema   of  the 
larynx,  430 
laryngoscopy,  illus.,  292 
Infra-mammary  region,  4,  8 
Infra-scapular  region,  4,  8 
Infra-thyroid  laryngotomy,  476 
Ingals,  emballometer,   illus.,   33;    flat  trocar, 
illus.,  79;    drainage  tubes  for  empy- 
ema, illus.,  81 ;  nasal  speculum,  illus., 
301 ;  modification  of  Shurly's  battery, 
illus.,  345;  cautery  electrodes,  illus., 
346;  tonsil  forceps,  illus.,  373;  laryn- 
geal  applicator,  illus.,  405;  chromic 
acid      applicator,      galvano-cautery 
handle,    illus.,  409;    punch   forceps, 
illus.,  485;  nasal  scissors,  illus.,  545 
nasal  syringe,  illus., 550;  snare,  illus. 
567 ;  nasal  dressing  forceps,  illus. ,  576 
electric  lamp  for  transillumination 
581 ;    drainage  tube  for  the  antrum 
illus.,  583;    septum    forceps,    illus. 
septum     knife,     illus.,    596;     right 
angle     cutting    forceps,    597;    nasal 
saws,  illus.,  599;  nasal  spatula,  illus., 
heavy -bone     scissors,     illus.,    nasal 
bone   forceps,  illus.,  600;   post -nasal 
snare  applicator,  illus.,  623 
Inhalations,   formula?,  vapor,    649-651 ;   spray, 

651-653;  dry,  654;  fuming,  654,  655 
Inhaler,  649,  654 

Injections  for  pleurisy,  stimulating,  81 
Inspection,  9-14,  86,  88,  183,  184,  272,  302 
Insufflations,  formulas,  656,  657 
Insufflator,  illus.,  536 
Intensity  of  sound,  22,  39,  41 

of  heart  sounds,  modified  by  disease,  191 
of  vocal  resonance,  modified  by  disease,  55 
Inter-arytenoid  fold,  illus.,  299 
Intercostal  neuralgia  or  pleurodynia,  diff.  fr. 
pleurisy,  68;   fr.  pneumonia,  119;  fr. 
angina  pectoris,  251 
Interlobular  emphysema,  107 

pneumonia,  often  included  in  lobular  pneu- 
monia, 123 
Intermittent   dilatation  preferred  in  stenosis 
of  the  larynx,  459 
rhythm  of  the  heart,  193 


672 


INDEX. 


Intermittent  venous  murmurs,  207 
Internal  treatment,  diphtheria,  337 
International  clinics,  operating  on  benign  tu- 
mors in  the  larynx,  F.  H.  Hooper,  473 
Congress  Laryngology  and  Otology,  Trans- 
actions, myxomata  transformed  into 
sarcomata,  Schiffers,  566 
Journal  of  Surgery  and  Antiseptics,  nasal 

vascular  tumors,  J.  O.  Roe,  570 
Medical  Annual,  tachycardia,  L.  Bouveret, 

249 
Medical  Congress,  Transactions,  epistaxis, 
Harkin,  561 ;  Walton  Brown,  562 
Internationale  klinisehe   Rundschau,  pericar- 
ditis, von  Stoffela,  214:    nasal  tuber- 
culosis,    Michelson,     578;      adenoid 
growths  in  deaf-mutes,  Wroblewski, 
614 
Interrupted  or  cog-wheel  respiration,  43 
Interscapular  region,  4,  7 

Interstitial  pneumonia,  often  included  in  lobu- 
lar pneumonia,  123 
pneumonia,  syn.   of  fibroid  phthisis,   128, 
167 
Intubation    in    diphtheria,    croup,  and   other 
Throat  diseases,  338,  397,  415.  418-421, 
428,   429,    432,   450,   453,   458,   459,   472, 
484,  490,  513,  515 
described,  418-421,  458,  459 
instruments,  418 
Intumescent  rhinitis,  528,  531-540 

anat.,  path.,  etiol.,   symp.,  531;  diag. , 

prog.,  treat.,  534 
diff.    fr.    simple  chronic  rhinitis;    fr. 
nasal  mucous  polypi,  534;  fr.  hyper- 
trophic rhinitis,  534,  542 
Inversion  of  a  patient  to  remove  foreign  bodies 

from  the  trachea.  491 
Involution  of  the  trachea.  485,  486 

etiol.,  symp.,  diag.,  prog.,  treat.,  486 
Iodine  for  immunity  to  tubercular  virus,  172; 
for  tuberculosis,  631 
trichloride  in  surgery,  441 
Inspiratory  power  less  than  expiratory,  20 
Irritability  of  the  tongue  remedied  for  rhino- 
scopy, 304 
Irritable  fauces  an  obstacle  to  laryngoscopy, 
289;   remedied,  305 
heart  of  soldiers,  249 
Irritative  cough,  treat.,  498 
Italy,  rhinoscleroma  in,  588:  goitre  in,  629 

Jaccoud,  pleurisy,  83 

Jackson,  Hughlings.  nose-bleeding  preceding 
apoplexy,  560 

Japan,  distoma  pulmonale,  150 

Jarvis,  small  nasal  speculum,  illus. ,  301;  tu- 
bercular laryngitis,  441 ;  snare  for- 
ceps, 473;  rhinitis,  545;  snare,  567: 
nasal  vascular  tumors,  570:  drill,  598 

Jaworski,  pneumonia  contagious.  116 

Johnson,  H.  A.,  inspection  in  phthisis,  162 

Journal  American  Medical  Association,  pneu- 
monia contagious,  Jaworski,  116 
de   Medecine   de  Paris,  epileptic  asthma, 
Poulet,  104 


Journal  of  Laryngology,  lepra  of  the  larynx, 

Morell  Mackenzie.  454 
Jugular  veins,  collapse  of  the.  207 
June  cold,  syn.  of  hay  fever,  553 

Keloid  diff.  fr.  rhinoscleroma,  589 

Kennedy,  fatty  heart,  242 

Klebs-Loffler  bacillus  a  cause  of  diphtheria, 
329 

Klemperer,  G.  and  F.,  experiments  with  blood 
serum  or  anti-pneumatoxin  in  pneu- 
monia, 123 

Knife,  laryngeal,  474;  septum,  596,  599 

Knife-grinder's  rot,  syn.  of  dilatation  of  the 
bronchial  tubes,  100 

Knight,  stethoscope,  illus.,  36 

Charles  H.,  galvano-cautery  in  chronic 
follicular  tonsillitis,  372;  nasal  osse- 
ous cysts,  570 
F.  I.,  lupus  of  the  larynx,  451;  chorea 
laryngis,  501,  502;  laryngeal  vertigo, 
504 

Koch,  bacilli  in  lupus  of  the  larynx,  451 
tubercle  bacillus,  159 

tuberculin,  disastrous  use  of.  454;  in  tu- 
berculosis of  nares,  579;  curative  in 
lupus  of  the  nares,  588;  inactive  in 
rhinoscleroma,  589 

Konig,    canula,  486,  488 

Kramer,  head-band  for  reflector  in  laryngo- 
scopy, 277 

Krauseand  Herynge,  treatment  of  acute  tuber- 
cular sore  throat,  352 
operations  on  the  antrum,  582 

Krishaber,  illuminator,  illus.,  278;  thyroto- 
my.  475 

Kuhn,  pneumonia  contagious,  116 

Labus,  Carlo,  trachoma  of  the  vocal  cords,  408 
Lactic  acid  in  diseases  of  the  throat  and  nose, 

335,  336,  380,  381,  417,  578 
Lactose  diuretic,  230 

Laennec,   theory   of  the  cause  of   pulmonary 

emphysema, 20;  mediate  auscultation, 

34;  bronchial  respiration,  45;  rales,  51 

La  France  Medicale,  carbon  dioxide  in  asthma, 

Weill,  106 
Lamp  for  laryngoscopy,  German  student's,  279; 
for  transillumination  of  the  nasal  cavities, 
electric,  581 
Lancet,  laryngeal,  397 
Larry,  aerial  goitre,  486 
Laryngeal  and  tracheal  respiration,  41 
applicator,  405 
cough,  59 
electrodes,  509 
forceps,  illus.,  471 
knives,  474 
lancet,  397 

phthisis,  syn.  of  tubercular  laryngitis,  434 
tuberculosis,  syn.  of  tubercular  laryngitis, 

434 
tubes.  418,  459  (see  intubation) 
tumors,  illus.,  463-485 

diff.  fr.  syphilis,  447 
vertigo,  treat.,  504 


INDEX. 


673 


Laryngectomy,  modes  described.  482,  483 
Laryngismus  stridulus,  syn.  of  spasm  of  the 

glottis,  496 
Laryngitis,  acute,  393-397 

chronic,  398-408 

chronica,  syn.  of  chronic  laryngitis,  398 

due  to  small-pox,  455 

erysipelatous,  428,  429 

exudative,  syn.  of  membranous  croup,  411 

of  measles,  455 

of  scarlet  fever,  of  small-pox,  455 

phlegmonosa,  syn.  of  phlegmonous  laryn- 
gitis, 427 

sero-purulenta,  syn.  of  phlegmonous  laryn- 
gitis, 427 

subacute,  397,  398 

submucosa  purulenta,  syn.   of  phlegmon- 
ous laryngitis,  427 

syphilitic,  443-450;  in  infants,  449,  450 

traumatic,  398 

tubercular,  434-443 
Laryngopharyngeal  sinuses,  296 
Laryngophony,  54 
Laryngoscope,    a,  272;    preferred    form,    282; 

manipulation  of,  283-289 
Laryngoscopic  mirror  in  position,  illus.,  286 
Laryngoscopy  reflector,  illus.,  283 
Laryngoscopy,  illus.,  272-292 

infraglottic,  292 

obstacles  to,  289-292 
Laryngotomy,    supra-thyroid,     infra-thyroid, 

475,  476,  642 
Larynx,  a  normal,  illus.,  293,  295;  of  women, 
in  forming  head  tones,  illus.,  298 

abscess  of  the,  429,  430 

anaesthesia  of  the,  499,  500 

artificial,  482 

benign  tumors  of  the,  465-476 

cancer  of  the,  476-483 

chronic  stenosis  of  the,  456-459 

cystic  growths  of  the,  466 

diseases  of  the,  394-515 

dislocation  of  the,  490 

extirpation,  partial,  complete,  481-483 

foreign  bodies  in  the,  490-492 

fracture  of  the,  489,  490 

hypersesthesia  of  the,  500,  501 

hypertrophy  of  the,  455 

illumination  of  the,  275-283 

lepra  of  the,  454 

lupus  of  the,  451-454 

malignant  tumors  of  the,  476-483 

morbid  growths  of  the,  463-483 

neuralgia  of  the,  500,  501 

oedema  of  the,  430-433 

pareesthesia  of  the,  500,  501 

resection  of  the,  481 

spasm  of  the,  in  adults,  497,  498 

ventricles  of  the,  297 
La  Semaine  M6dicale,  causes  of  angina   pec- 
toris, 251 
Lateral  region,  3 
La  Tribune  Medicale,  lactose  diuretic,  Germain 

S6e,  230 
Laugenbeck,  retro-nasal  fibrous  tumors,  621 
Lawrence,  retro-nasal  fibrous  tumors,  621 
43 


Lazarus,  heredity  in  asthma,  303 

Leared,  binaural  stethoscope,  35 

Lefferts,  George  M.,  history  of  lupus  in  the 
larynx,  451 ;  eversion  of  the  ventri- 
cles of  Morgagni,  483;  chorea  laryn- 
gis,  501 ;  retro-nasal  cystic  tumors, 
626 

Leichtenstern,  pleurisy,  71 ;  empyema  in  chil- 
dren, 77 

Leidy,  Joseph,  thyrotomy,  475 

Leiter  coil  for  applying  cold  through  a  circu- 
lation of  water,  in  tonsillitis,  369 ;  in 
croup,  416 

Lepra  of  the  larynx,  illus.,  454,  455 

path.,  etiol.,  symp.,  diag.,  prog., treat.,  454 
diff.  fr.  benign  tumors,  469 

Leptothrix  buccalis,  376 

Leucoplakia  buccalis,  360-362 

syn.,  anat.,  path.,  etiol.,  360;  symp., 

diag. ,  361 ;  prog. ,  treat. ,  362 
diff.  fr.  professional  patches,  357; 
fr.  smoker's  patches,  fr.  mercurial 
patches,  fr.  syphilitic  patches,  fr. 
cancer,  fr.  psoriasis  linguae,  361,  362 
buccalis  et  lingualis,  syn.  of  leucoplakia 
buccalis,  360 

Levret,  laryngoscopy,  272 

Lewin,  benign  growths  in  the  larynx,  465 

Lewis,  foreign  bodies  in  the  trachea,  492 

Leyden,  cause  of  asthma,  103 

LiSgeois,  cause  of  angina  pectoris,  250 

Ligation  for  extirpation  of  tumors,  622 

Lime-water  vapors  in  diphtheria,  416 

Lincoln,  R.  P.,  nasal  cancerous  tumors,  573;- 
extirpation  of  nasal  tumors,  621 

Linsley's  translation  Frankel's  Bacteriology,, 
staining  bacilli,  165 

Lipomata,  467 

Liston,  laryngoscopy,  272 

Litten,  pulmonary  thrombosis  and  embolism, 
138 

Liver,  enlargement  or  hypertrophy  of,  68,  70 

Lobar  pneumonia,  113-123 

syn.,    anat.,    path.,    113;     etiol.,    115; 
symp.,    116;    diag.,   119;    prog.,  121 1 
treat.,  122 
diff.  fr.  capillary  bronchitis,  97;  fr.  lo- 
bular pneumonia,  127 

Lobular  pneumonia,  123-128 

syn.,  anat.,  path.,  123;  etiol.,  symp., 
124;  diag.,  125;  prog.,  127;  treat.,  128 
diff.  fr.  capillary  bronchitis,  97;  fr. 
capillary  bronchitis,  fr.  pulmonary 
collapse,  fr.  lobar  pneumonia,  fr. 
acute  tubercular  phthisis,  125-128 

Local  anaesthesia  produced  by  a  pigment  of 

morphine,  carbolic  acid,  tannic  acid, 

glycerin,  water,  442 

anaesthesia,  produced  by  cocaine,  457,  470, 

495,  544,  557.  568,  582,  603,  616,  617,  623 

anaesthesia,  pigments,  formulae,  655 

Loewenberg,  forceps,  illus.,  617 

London    Hospital   Clinical   Lectures  and   Re- 
ports, nose-bleeding  preceding  apo- 
plexy, Hughlings  Jackson,  560 
Lancet,  diagnosis  of  congenital  disease  ot 


074 


INDEX. 


the  heart  in  children.  Sansom.  246: 
removing  foreign  bodies  from  the 
trachea,  Padley.  494;  goitre.  Morell 
Mackenzie,  631 ;  tube  used  in  stricture 
of  the  oesophagus.  Charters  J.  Sy- 
monds.  636 
London  Practitioner,  treatment   of  ulcerative 

endocarditis.  Sansom,  223 
Loomis.  A.  L..  percussion  sounds,    28;    treat- 
ment of  pleurisy,  72,  7S;  double  pneu- 
monia, 115;   treatment  of  pulmonary 
hemorrhage,  136;  mortality  in  infants 
from  atelectasis  following  bronchitis, 
141;   rhythm  of  heart  sounds,  illus., 
183;   reduplication   of   heart  sounds, 
194  ;  endocarditis.  221 ;  simple  cardiac 
hypertrophy,    234;     thoracic   aneur- 
isms, 265 
Henry  P.,  bacilli   in  healthy  persons,  159 
Lozenges,  trochisci  or.  formula?.  647-649 
Lubet-Barbou,  spasm  of  the  glottis,  496 
Lumniczer,  Josef,  cause  of  putrid  bronchitis, 

91 
Lung  fever,  popular  syn.  of  pneumonia,  113 
Lungs,  apoplexy  of  the,  15 
collapse  of  the.  70 
consolidation  of.  237,  264 
hydatid  cysts  of  the,  148-150 
retraction  of  the,  237 
syphilitic  disease  of  the,  151,  152 
L'Union  Medicale,  Klebs-Loffler  bacillus.  Roux 
and   Yersin,   329;    case   of  excessive 
nose-bleeding,  Martineau,  560 
Lupus  exedens,  non-exedens,  587 
of  the  larynx,  illus..  451-454 

anat..  path.,  etiol.,  451;  symp. .  diag., 

452;    prog.,  treat.,  453 
diff.    fr.  tuberculosis,    fr.    syphilis,  fr. 
cancer,   453.  454,  479;    fr.    benign   tu- 
mors, 469 
of  the  nares,  587,  588 

anat.,  path.,  etiol.,  symp.,  diag.,  587; 

prog.,  treat.,  588 
diff.      fr.    atrophic     rhinitis,    549:    fr. 
syphilis,  fr.    epithelioma,    fr.   tuber- 
culosis, 587 
of  the  pharynx,  diff.    fr.    scrofulous  sore 

throat,  349 
vulgaris.  549 

vulgaris  laryngis.  Chiari  and  Riehl.  451 
Luschka's    tonsil    fsee    hypertrophy    of    the 

pharyngeal  tonsil) 
Lyon  Medicale,  cause  of  angina  pectoris,  251 

McBride.  anaesthesia  of  the  larynx.  499;  em- 
pyema  of  the  antrum,  580 

McDonald.  Greville,  atrophic  rhinitis  most 
C'  mmon  in  girls.  547;  atrophic  rhi- 
nitis. 552;  nasal  osseous  cysts,  570; 
empyema  of  the  antrum.  581 ;  hyper- 
trophy of  the  pharyngeal  tonsil,  614 

Mackenzie.  John  N.,  syphilitic  sore  throat  in 
infants.  356 :  syphilitic  laryngitis  in 
infants.  44'.':  hay  fever  related  to  con- 
dition in  nasal  passages,  553 ;  forceps. 
617 


Mackenzie,  Morell.  rack  movement  bull's-eye 
condenser,  illus..  278.  279;  fossa  in- 
nominata.  297;  erysipelatous  sore 
throat,  316;  lactic  acid  in  diphtheria, 
335:  syphilitic  sore  throat,  356;  laryn- 
geal lancet,  illus.,  397;  identity  of 
diphtheria  and  croup,  411;  syphilitic 
laryngitis,  443,  445;  lepra  of  the 
larnyx.  454;  laryngeal  dilator,  illus., 
458;  laryngeal  tumors,  463.  465;  tube 
forceps,  illus..  472;  guarded  wheel 
ecraseur,  474:  thyrotomy.  475,  476; 
laryngeal  cancer,  477;  mode  of  com- 
plete extirpation  of  the  larynx,  482; 
tracheocele,  486;  syphilis  of  the 
trachea,  487;  laryngeal  electrodes, 
illus.,  509;  rhinitis,  525;  hay  fever, 
556;  mucous  polypi,  565;  nasal  pa- 
pillary tumors,  569:  nasal  syphilis, 
574.  577:  tonsillitis.  574;  anosmia, 
592;  deflection  of  the  septum,  594; 
rhino-pharyngitis,  607,  609;  throat 
deafness.  613;  goitre,  631;  paralysis 
of  the  oesophagus,  639,  640;  electric 
inhaler,  649 

MacNamara,  epistaxis,  561 

Maggots  in  the  nose,  syn.,  of  myosis  narium, 
605 

Malformations  and  new  growths  of  the  uvula, 
359 

Malignant    (see  also  cancer)    disease    of    the 
oesophagus  cliff,  fr.  paralysis,  639 
endocarditis,  syn.   of  acute    endocarditis, 

219 
growths  on  uvula,  360 
tumors  diff.  fr.  benign  tumors,  469 
tumors,  nasal,  572,  573 
tumors  of  the  larynx,  illus.,  476.  483 

anat.,   path.,    symp.,    476;    diag.,  479; 

prog.,  treat.,  480 
diff.  fr.  syphilis,  fr.  chronic   catarrhal 
inflammation,  fr.  lupus,  fr.  tubercu- 
lar  laryngitis,   fr.   benign   growths, 
478.  479 
tumors  of  the  naso-pharynx,  anat.,  path., 
etiol.,  symp.,  diag.,  prog.,  treat.,  625 
diff.    fr.    retro-nasal  fibro-mucous  tu- 
mors,   625;   fr.     nasal    cartilaginous 
tumors,  571 

Mammary  or  nipple  line,  6 
region,  4,  5 

Marey,  sphygmograph,  illus..  208 

Martineau.  case  of  excessive  nose-bleeding,  560 

Massage  with  foreign  bodies  in  the  oesophagus, 
642 

Matheson,  pneumonia,  contagious,  116 

Mathieu.  tonsillitome,  illus.,  372 

Measles,  sore  throat  of .  322.  323;  laryngitis  due 
to.  455;  nasal  affections  in,  591 

Meatus,  inferior,  middle,   superior,  309 

Mediastinal  tumors,  solid,  193,  267,  268 
diff.   fr.  pericarditis,  216 

Mediate  auscultation.  34 
percussion.  21 

Medical  Xews.  danger  in  washing  pleural  cav- 
ity, Bowditch,  resection  of  ribs,   W. 


INDEX. 


675 


M.  Strickler,  78;    promotion  of  renal 
secretion  in. children  with  capillary 
bronchitis,  98;  asthma  due  to  poison 
in  the  blood,  Robinson,  104; 
Medical    Press     and    Circular,    pneumonia  — 
contagious,  Mosler,  116 
Record,  acute  pleurisy,  Drzewiecki,  72 
Register,    pneumonia    contagious,    Wells, 

116 
Society  of  London,  Transactions,  acute  ton- 
sillitis, Higston  Fox,  363 
Membranous  croup,  14,  411-426 

syn.,   anat. ,   path.,   etiol.,  411;  symp., 
diag. ,  412,  413;  prog.,  415;  treat.,  416 
diff .  f r.  acute  laryngitis,  396 ;  f r.  catar- 
rhal laryngitis,  fr.  laryngismus  stri- 
dulus, fr.  diphtheria,  413-415 
laryngitis,  syn.  of  membranous  croup,  411 
sore  throat,  simple,  324-327 
Meningitis  diff.  fr.  pneumonia,  121 
Mensuration,  9,  16-20,  86 
Menthol  and  alboleue  spray,  441,  551 
Mercurial  patches  diff.  fr.  leucoplakia  bucca- 

lis,  361 
Mercury  to  infants,  mode  of  applying,  577 
Mesosternal  line,  7 
Metallic  tinkling,  20,  54,  87 
Mexico  for  phthisis,  175;  nasal  syphilis  in,  574; 

myasis  narium  in,  605 
Michelson,  nasal  tuberculosis,  578 
Michigan  for  hay  fever,  555 
Micrococcus  of  Friedlander  exciting  pulmon- 
ary inflammation,  15 
Microscopic   examination,    lobar   pneumonia, 

114 
Middle  meatus,  illus.,  309 

turbinated  bodies,  illus.,  308 
Miliary  tuberculosis,  acute,  165-167 
Milk  most  important  nutritious  drink  in  diph- 
theria, 334 
spots,  212 
Minnesota  for  phthisis,  175 
Minot,  pneumonia  in  children,  115 
Mirrors  for  laryngoscopy,  throat,  273 ;  position 

for,  manipulation  of,  286-289 
Mitral  area,  illus.,  198 

constriction,  illus.,  210 
murmurs,  198.  201 
obstruction,  225,  228.  230 
regurgitation,  illus.,  209,  225,  228 
stenosis,  225 
valves,  7,  178 
Moist  rales,  48.  50 
Montana  for  phthisis,  175 
Morbid  growths  in  the  larynx,  14,  463-485 
anat.,  path.,  etiol.,  463;  symp.,  464 
Morbus  caeruleus,  246,  247 

syn.,  symp.,  diag.,  246;    prog.,  treat., 
247 
Morgagni,  eversion  of  the  ventricle  of,  483 
Morsen,  creasote  for  phthisis,  173 
Mosetig-Moorhof  mode  of   injecting  iodoform 

in  goitre,  631 
Mosler,  pneumonia  contagious,  116 
Mountains  for  phthisis  175;  for  hay  fever,  555 
Mount  Bleyer,  tongue  depressor,  illus.,  464 


Moure,    regeneration   of  atrophied  structure, 

550 

Mucous  click,  48,  52 

patches,  353 

polypi,  myxomata  or  true,  466 
polypi,  nasal,  564-568 
rales,  48,  50 
tubercles,  353 
Mulhall,  J.  C,  falsetto  voice,  503 
Multilocular  pleurisy  diff.  f r.  other  forms,  83 
Miinchener  medicinische   Wochenschrift,    the 
aneurismatiscope, Ferdinand  Schnell, 
261 
Murmurs,  vesicular,  39;  cardiac,  195-211 ;   exo- 
cardial  or  pericardial  friction  sounds 
or,  195;    endocardial,  196;    diastolic, 
203,  204;   ventricular,  congenital  has- 
mic,  204;  subclavian,  206 
Myalgia  diff.  fr.  angina  pectoris,  251 
Myasis  narium,  605,  606 

syn.,  etiol.,   symp.,   diag.,   prog.,  605; 
treat.,  606 
Mycosis  of  the  tonsils,  376,  377 

anat.,  path,  etiol.,  symp.,  diag.,  376 
diff.   fr.    acute   and  chronic  follicular 
tonsillitis,  376,  377 
Myocarditis,  213,  231-233 

anat.,  path.,  etiol.,  symp.,  231;  diag., 
prog. ,  treat. ,  232 
Myxomata  or  true  mucous  polypi,  illus.,  466 

Nares,  tuberculosis  of  the,  578,  579;  lupus  of 

the,  587,  588 
Nasal  affections  in  acute  diseases,  591 
bone  forceps.  600 
bones,  dislocation  of  the,  594 
bony  tumors,  571,  572 

syn.,    anat.,   path.,  etiol.    symp.,  571; 

diag.,  prog.,  treat.,  572 
diff.    fr.    exostoses,    fr.    rhinoliths,  fr. 
cancer,   572 
burrs,  illus. ,  546 

cartilaginous    tumors,    syn.,  anat.,  path., 
symp.,  diag.,  prog.,  treat.,  571 
diff.  fr.  fibrous  polypi,  fr.  malignant  tu- 
mors, fr.    exotoses,  fr.  ecchondroses, 
fr.  bony  tumors,  571 
cavities,  diseases  of  the,  519-606 
douches,  illus.,  551 
douches,  formulae,  658 
dressing  forceps,  576 
fibrous  polypi,  syn. ,  treat. ,  569 
malignant  tumors,  572,  573 

anat.,  path. ,  572;   etiol.,  symp.,  diag., 

prog.,  treat.,  573 
diff.  fr.   rhinoliths,  fr.  foreign  bodies, 
fr.  abscess,  fr.  benign  growths,  573 
mucous  polypi,  564-568 

syn.,  anat.,  path.,  etiol.,  symp.,  564 
diff.  fr.  intumescent  rhinitis,  534;  fr. 
hypertrophic  rhinitis,  543;  fr.  de- 
viation of  the  septum,  fr.  thick- 
ening of  the  turbinated  bodies, 
fr.  chronic  abscess  of  the  nasal  sep- 
tum, fr.  foreign  bodies  in  the  nose, 
fr.    fibrous,  sarcomatous,   and    can- 


676 


INDEX. 


cerous  growths,  565;  fr.  empyema. 
581;  fr.  chronic  suppurative  ethmoi- 
ditis.  585;  fr.  haematoma,  602:  fr.  for- 
eign bodies,  603;  fr.  hypertrophy  of 
the  pharyngeal  tonsil,  616;  fr.  retro- 
nasal fibrous  tumors.  621 :  fr.  retro- 
nasal fibro-mucous  tumors.  625 
Nasal  myxomata.  syn.  of  nasal  mucous  polypi. 
564 
osseous  cysts,  anat..  path.,  etiol.,  symp., 

diag.,  treat..  570 
papillary  tumors.  569.  570 

syn..  anat..  path.,  symp..  diag.,  prog., 
treat..  569 
probe,  flat.  537 
saws,  599.  600 
scissors.  545.  600 

septum,    deflection   of    the.    594;    ecchon- 
droma  and  exostosis  of  the.  507:  per- 
foration  of   the,  601 :    haematoma  of 
the.  002 :  abscesses  of  the,  603 
snare.  359.  507 
spatula.  600 
speculum.  301 
spud,  illus..  599 
syringe.  550 
trephines,  illus.,  546 
vascular  tumors,  syn..  treat..  570 
Naso-pharynx.  cystic  tumors  of  the.  626 
diseases  of  the,  607-626 
malignant  tumors  of  the.  625 
Natural  light  for  laryngoscopy,  282 
Navratil.  dilator.  457 
Nebraska  for  phthisis,  175 

Neoplasms  of  the  heart,  rare,  246;   of  the  lar- 
ynx. 464 
Nervous  aphonia,   syn.  of  bilateral  paralysis 
of  the   lateral    crico-arytenoid   mus- 
cles. 508 
cough,  treat.,  498.  499 
Netter.  diplococcus  pneumoniae,  115 
Neuralgia,  iutercostal.  68 
of  the  larynx.,  500.  501 

anat.,  path.,  etiol.,  symp.,  diag.,  500; 

prog.,  treat.,  501 
diff.  fr.  chronic  rheumatic  sore  throat, 
319 
of  the  pharynx,  treat.,  389 
Neuroses  of  the  pharynx,  388-392 
Neurotic  or  functional  disease  of  the  '.heart, 
247-249 
etiol.,  symp.,  247;  diag.,  prog.,  treat., 

248 
diff.  fr.  chronic  endocarditis,  226 
Newcomb,  James  E..   electrolysis  in  disease 

of  septum,  601 
New  Hampshire  for  hay  fever,  555 
New    Mexico  for   phthisis,    175;     rhinitis    in, 

527 
New  York  Medical  Journal,  pneumonia,  infec- 
tive. Delafield,  115;  pneumonia,  con- 
tagious. Wells,  116;  acute  tubercular 
»  sore  throat.  Gleitsmann.  352;  electric- 
ity in  rhinitis,  D.  Bryson  Delavan. 
552;  nasal  vascular  tumors,  J.  O.  Roe, 
570 


New  York  Medical  Record,  iodide  trichloride 
in  surgery,  Wm.  T.  Belfield.  441 ;  ever- 
sion  of  the  ventricles  of  Morgagni, 
483;  fracture  of  the  nose,  J.  O.  Roe, 
594  ;  electrolysis  in  disease  of  septum, 
James  E.  Newcomb,  601 
Night  sweats  remedied.  171 
Nipple  line,  mammary  or,  0 
Nitroglycerine  for  angina   pectoris.  252:  athe- 
roma of  the  aorta.  256 
Nitrous  oxide  gas  for  anaesthetic  in  aspiration 

in  empyema.  80 
Normal  bronchial  whisper,  58 
bronchophony.  55 
radical  pulse,  illus.,  208 
vesicular  resonance,  25 
vocal  fremitus.  15 
vocal  resonance.  54,  55 
North  Carolina  mountains  for  phthisis,  175 
Nose  bleeding,  syn.  of  epistaxis,  559 
congenital  deformity  of  the,  593 
diseases  of  the.  518-626 
foreign  bodies  in  the.  603,  604 
fractures  of  the.  593.  594 
furunculosis  of  the.  558,  559 
syphilis  of  the.  574-577;  cdngenital.  577 
Nottinghamshire,  goitre  in,  629 

Obstacles  to  laryngoscopy.  28! 

to  posterior  rhinoscopy,  304-306 
Obstruction,    aortic,    mitral,    tricuspid,    pul- 
monic. 225.  220.  228,  230 
Obturator  for  intubation  tubes,  illus..  418 
Odontological  Society  Transactions,  empyema 
of   the   antrum,  Christopher  Heath, 
582 
O'Dwyer,  Joseph,  intubation.  338,  415,  490;  in- 
tubation instruments,  illus..  418,  420; 
laryngeal  tubes,  433.  4:54.  449,  457,  459, 
485,  488,  47ii.  4;-,' 
CEdema  glottidis,  syn.  of  oedema  of  the  lar- 
ynx, 14.  4:% 
of  the  larynx,  430-433 

syn.,   430;    etiol.,    symp.,    431;  prog., 

treat..  432 
diff.  fr.    retropharyngeal  abscess.  384; 
fr.   chronic   laryngitis,    402,   403;   fr. 
tubercular  laryngitis,  439 
of  the  uvula,  acute  inflammation  and,  358 
pulmonary,  15,  42.  142-144 
(Edematous  laryngitis,  syn.  of  cederna  of  the 

larynx,  430 
CEnothera  biennis  unsatisfactory  with   pertus- 
sis, 155 
Oertel,  carbolic  acid  in  diphtheria,  336;  pilo- 
carpine in  diphtheria,  337 
Oesophageal  bougie,  635 
forceps,  flexible,  641 
tube.  387,  388,  392 
CEsophagismus.  syn.  of  spasm  of  the  oesopha- 
gus. 037 
Oesophagitis.  032-634 
acute,  632.  633 
chronic.  633,  634 
OEsophagotome,  636 
CEsophagotorny,  642 


INDEX. 


677 


Oesophagus,  compression  of  the,  637 

diseases  of  the,  632-643 

foreign  bodies  in  the,  640-642 

parsesthesia  of  the,  642.  643 

paralysis  of  the,  638-640 

spasm  of  the,  637,  638 

stricture  of  the,  634-637 
Oil  atomizer,  536 
Olivary  bougies,  635 

Oilier,  retro-nasal  fibrous  tumors,  621,  622 
Opiates  prohibited  in  capillary  bronchitis,  98 
Opium  objectionable  in  pneumonia.  123 
Orth,  gangrene  in  lobar  pneumonia,  115 
Osseous  cysts,  nasal,  570 

tumors  diff.  fr.  nasal  mucous  polypi,  566 
Osteoma  diff.  fr.  rhinoliths,  605 
Osteomata   of   the   nose,   syn.   of   nasal   bony 

tumors,  571 
Outgrowths  diff.  fr.  benign  tumors,  469 
Owsley,  F.  D.,  spray  of  solution  of  cloves  in 

laryngitis,  442 
Oxyhydrogen  light  for  laryngeal  illumination, 

275 
Ozsena  diff.  fr.  empyema  of  the  antrum,  581 

Packing  nasal  cavities  to  check  bleediDg,  619 

(See  Plugging :  see  Tampon) 
Padley,    method  of  removing  foreign   bodies 

from  the  trachea,  494 
Palasciano,  fibromata,  621 
Palate  retractors,  306 

ulcerative  destruction  of,  354 
Pallor  in  chronic  pulmonary  disease,  11 
Palpation,  9,  14-16,  185 
Panas,  fracture  of  the  larynx,  .489 
Papillary  growths  on  the  uvula,  359 
Papillomata  of  the  larynx,  illus. .  465,  476 

of   the  nares,  syn.  of   nasal   papillary  tu- 
mors, 569 
Parsesthesia  of  the  larynx,  500.  501 

anat.,  path.,  etiol.,  symp.,  diag. ,  500; 
prog.,  treat.,  501 
of  the  oesophagus,  642,  643 

etiol.,  symp.,  diag.,  prog.,  treat.,  643 
diff.  fr.  foreign  bodies,  641 
Parsesthesia  of  the  pharynx,  389 

etiol.,  prog.,  treat.,  389 
Paralysis  of  the  abductors  diff  fr.  stenosis   of 
the  larynx,  457  (see  Paralysis  of  the 
posterior  crico-arytenoid  muscles) 
of  the  arytenoid  muscles,    symp.,   diag., 

treat.,  511 
of  the  crico-thyroid  muscles,  illus.,  symp., 

diag.,  prog.,  treat.,  506 
of  the  oesophagus,  638-640 

anat.    path.,  638;   etiol.,  symp.,  diag., 

639;  prog,  treat.,  640 
diff.  fr.  spasm  of  the  pharynx,  390;   fr. 
stricture  of  the  oesophagus,  635:   fr. 
spasm,  fr.  malignant  disease,  639,  640 
of  the  pharynx,  391,  392 

etiol.,  symp.,  diag.,  prog.,  391;  treat., 

392 
diff.  fr.  spasm  of  the  pharynx,  390 
of  the  posterior  crico-arytenoid  muscles, 
bilateral,  511-513;  unilateral,  514 


Paralysis    of    the    posterior   crico-arytenoid 
muscles,  diff.  fr.  stenosis  of   the  la- 
rynx, 457 
of  the  thyro-arytenoid  muscles,  illus.,  507, 
508 
anat.,  path.,  etiol.,  symp.,  diag.,  prog., 
treat..,  507 
of  the  tbyro-epiglottic  and  ary-epiglottic 
muscles,  505,  506 
etiol.,  symp.,  diag.,  prog.,  treat.,  505 
of  the  vocal  cords,  diff.  fr.  acute  laryngitis, 
396;  fr.  chronic  laryngitis,  402 
Parosmia,  diag.,  treat.,  591 
Partial  extirpation  of  the  larynx  described,  481 
Passive  aneurism  of  the  heart,  syn.  of  dilata- 
tion of  the  heart,  239 
hypersemia,  133 
Pathological  Society  Transactions,  men  more 
affected  by  plastic  bronchitis,  Pea- 
cock, 99 
Pear-shaped  chest,  10 

Pectoriloquy,  55,  57;  whispering,  aphonic,  58 
Pendent    epiglottis    an    obstacle    to   laryngo- 
scopy, 291 
Percussion,  9,  21-33,  63,  85,  86,  88,  188;  mediate, 
immediate,  21;    in  health,  21-27;    in 
disease,  28-31;  auscultatory,  32,  33 
Perforated  concave  reflector,  275-278 
Perforating  ulceration  in  syphilitic  sore  throat, 

illus.,  353 
Perforation  of  the  nasal  septum,  601,  602 

treat.,  601 
Pericardial     effusion   and  hydro-pericardium 
diff.   fr.   eccentric  cardiac  hypertro- 
phy, 238 
friction  sounds  or  murmurs,  195 
Pericarditis,  13,  212-217 

anat.,  path.,    212;    etiol.,   symp.,  213; 

diag.,  215;  prog.,  treat.,  216 
diff.  fr.  pleurisy,  68,  215;   fr.  endocar- 
ditis, fr.  mediastinal  tumors,  216;  fr. 
endocarditis,    220;   fr.  chronic   endo- 
carditis,   226,    227;    fr.    hypertrophy 
and  dilatation  of  the  heart,  238;    fr. 
dilatation  of  the  heart,  241 
fibrinosa,  serosa,  212 
Pericardium,  the,  177 
Perichondritis    of    the    laryngeal    cartilages, 

chondritis  and,  433,  434 
Peri-pneumonia,  peri-pneumonia  vera,  syn.  of 

pneumonia.  113 
Pertussis  or  whooping-cough,  153-155 

anat.,  path.,  153;   etiol.,  symp.,  diag., 
prog.,  154;  treat.,  155 
Perverted  sense  of  smell,  591,  592 
Peter,  31.,  devised  the  plessigraph,  31;  pulsa- 
tion on  back  of  hands,  207 
Phagedenic  ulceration,  354 
Pharyngeal  bursa,  illus.,  309 

tonsil,  hypertrophy  of  the,  613-620 
Pharyngitis,  acute  follicular.  339,  340 
chronic  follicular.  340-346 
sicca,  or  atrophic  follicular,  343 
Pharynx,  anaesthesia  of  the,  388 

and  posterior  nasal  cavities,  vault  of  the, 
illus.,  307-310 


678 


IXDEX. 


Pharynx,  cancer  of  the.  380.    Si 
diseases  of  the,  382  -393 
foreign  bodies  in  the,     - 1      - 
hyperesthesia  of  the,  388,  389 
lupus  of  the.  349 
neuralgia  of  the.  389 
neuroses  of  the.  38 
paraesthesia  of  thi 
paralysis  of  tli*3.  391. 
scalds  and  burns  of  the,  392 
spasm  of  the 
tumors  of  the.  386 
Phlebectasis    laryngea,    anat..    path.,    etiol.. 

symp.,  diag.,  treat.,  409 
Phlegmonous  laryngitis,  427,  438,  431 

syn.,   etiol..  symp..  diag.,   427;    prog.. 

treat..  428 
diff.    fr.     laryngismus     stridulus,    fr. 
retro-pharyngeal  abscess,  fr.  foreign 
bodies  in  the  larynx,  fr.  diphtheritic 
laryngitis.  427.  428 
sore  throat,  syn.  of  phlegmonous  tonsilli- 
tis. 368 
tonsillitis,  368-370 

syn..  anat..  path.,  etiol.,  symp.,  diag., 

368;  prog.,  treat.,  369 
diff.  fr.  diphtheria.  332;    fr.  acute  ton- 
sillitis, 365 
Phthisis  infectious.  170 
fibroid,  167-169 

pulmonary,  13,  15.  89,  31,  161-164. 
of  the  heart,  syn.  of  atrophy  of  the  heart, 
242 
Physical  diagnosis.  3-59 

examination,  methods  of,  9-58 
examination  of  the  heart.  183-194 
Physiological  action  of  the  heart,  illus.,  180-183 
Physiology  of  the  heart,  anatomy  and,  177-1ni 
Pigeon  breast,  illus..  12 
Pigments,  formulae,  650.  656 
Pilocarpine  in  diphtheria.  337:    in   erysipelas. 

429;  in  cedema  of  the  larynx.  432 
Pincette,  291 

Pineapple  juice  in  diphtheria,  335 
Pins,  E. ,  pericarditis.  214 
Piorry,  mediate  percussion.  21 
Pitch  of  sound.  22.  39 

of  heart  sounds  modified  by  disease,  191 
Pityriasis  as  a  sign,  11 
Plastic  bronchitis,  99,  100 

syn..   anat.,    path.,   etiol.,    symp.,   99; 

prog.,  treat.,  100 
diff.  fr.  pleurisy,  fr.  pneumonia,  99 
or  dry  pleurisy,  t'.i 
Plessigraph,  the.  31 
Plessimeter.  pleximeter  or,  21 
Pleurisy,  acute.  61-72 
bilocular,  83 
circumscribed,  82.  150 
diaphragmatic.  83 
hemorrhagic.  61 
of  the  apex.  82 
or  empyema,  chronic,  76-82 
or  pleuritis.  12.  29.  60-84 
anat..  path.,  60 
diff.  fr.  plastic  bronchitis,  99;  fr.  pneu 


monia.  110;    fr.  pulmonary  collapse, 
141 
Pleurisy,  plastic  or  dry.  61 
subacute.  72-75 
multilocular.  83 
unilocular.  83 
sero-fibrinous.  61 
Pleuritic  friction    sounds  diff.  fr.  pericardial. 

196 
Pleuritis,  pleurisy  or.  60-84 
Pleurodynia  or  intercostal  neuralgia,  diff.  fr. 

pleurisy,  68;  fr.  pneumonia.  119 
Pleurotomy,  78 
Pleximeter.  21.  22 

Plugging  for  epistaxis.  561-663,  623,  624 
Pneumococci  in  endocarditis.  222 
Pneumo-hydropericardiuni.       etiol.,       symp., 

diag.,  prog.,  treat..    218 
Pneumo-hydrothorax.  illus..  85-88 
diag..  *7:  treat.,  88 

diff.  fr.  emphysema,  fr.    chronic  pleu- 
risy, fr.  diaphragmatic  hernia,  88 
Pneumonia.  113-129 
syn.,  113 

diff.  fr.  pleurisy.  69;    fr.  plastic  bron- 
chitis, 99;  fr.  pulmonary  (edema.  119, 
143:    fr.  abscess  of  the  lung.  130:   fr. 
pulmonary  collapse.  141 
bilious 

chronic  or  interstitial,  typhoid,  128 
from   disease  of  the  heart,  from  Bright"s 

disease.  128.  129 
lobar.  11:3-123 
lobular,  123-128 
Pneumo-hydropericardium.       etiol.,       symp., 

diag..  prog.,  treat..  318 
Pneumo-hydrothorax.  85 

diag..  87;  prog.,  treat..  88 
diff.  fr.  emphysema,  fr.  chronic    pleu- 
risy, fr.  diaphragmatic  hernia,  87,  88 
Pneumothorax.  13.  15.  31.  84,  85 

etiol.,  84;  symp.,  85:   diag.,  87;   prog., 

88;  treat.,  88 
diff.    fr.    emphysema.   87:    fr.    chronic 
pleurisy,  fr.    diaphragmatic    hernia, 
88;  fr.  emphysema.  110 
Pneumonorrhagia.    syn.    of    pulmonary    apo- 
plexy. 134.  137 
Pocket  tongue-depressor,  illus.,  271 
Polasciano,  retro-nasal  fibrous  tumors,  621 
Polikier,  B.,  foreign  bodies  in  oesophagus.  642 
Polypi,  nasal  fibrous. 

nasal  mucous.  5' 
Polypus,  diff.  fr.  phlegmonous  laryngit: 
Porcher,    self-retaining  uvula  and  palate  re- 
tractor, illus.,  306 
Position  for  rhinoscopy,  illus.,  304 
Positions    of    head    for    laryngoscopy,    good, 

poor,  illus.,  284.  285 
Posterior    crico-arytenoid    muscles,    bilateral 
paralysis  of.  511-513 
region.  3 

rhinoscopy,  illus..  302-306 
Post-nasal  catarrh,   syn.  of  rhinopharyngitis, 
607 
snare  applicator.  023 


INDEX 


679 


Post -nasal  syringe,  illus..  609 
Post-tracheotomy  vegetations.  485 

etiol..  symp.,  diag\ .  prog.,  treat.,  485 
Potain,  use  of  sterilized  air  in  pneumothorax, 

88 
Potassium  iodide  for  angina  pectoris,  247,  253 
Poulet,  epileptiform  asthma.  104 
Powder-blower  for  insufflation,  illus.,  536 
Powell,  R.  Douglas,  siphon  drainage  in  pleu- 
risy, 79;   cause   of   angina   pectoris, 
250;  aortitis,  254 
Prentiss,  classification  of  causes  of  slow  pulse, 

250 
Prescriptions,  formula?  for,  645-658 
Presystolic  venous  pulsation,  cause  of,  207 
Probang,  cotton,  405 
Probe,  flat  nasal.  537 
Processus  vocales,  the,  illus.,  299 
Professional  patches,  cliff,  fr.  leucoplakia  buc- 

calis,  361 
Progressive  bulbar  paralysis,  391 
Prolonged   interval    between   inspiration  and 
expiration,  cause  of,  43 
respiration,  cause  of,    44 
Prophylactic   treatment   most    important  for 
distoma   pulmonale,  151 ;     for    acute 
rheumatic  sore  throat,  321 :   for  diph- 
theria, 333,  334;   for  rhinitis  in  catar- 
rhal tendencies,  534 
Prophylaxis  in  phthisis,  170:  in  rhino-pharyn- 
gitis, 609 
Prudden,  T.  M.,  streptococcus   of   diphtheria, 

329 
Pseudo-angina  pectoris,   diff.   fr.  angina  pec- 
toris, 252 
Pseudo-apoplexy,  243 
Pseudo-diphtheria,  329 
Pseudo-membranous  bronchitis,  syn.  of  plastic 

bronchitis,  99 
Psoriasis    linguae,    diff.    fr.    leucoplakia    buc- 

calis,  361 
Pulmonary  apoplexy.  29.  137,  138 

syn.,  anat.,  path.,   etiol.,  symp.,  137; 
diag.,  treat..  138 
area,  illus.,  198,  199 
artery,  180;  aneurism  of  the,  264,  265 
cancer,  146-148 

anat.,  path.,   etiol.,  symp.,  146;   diag.. 

147,  prog.,  treat.,  148 
diff.  fr.  chronic  pleurisy,  fr.  phthisis, 
fr.  aortic  aneurism,  148 
Pulmonary  collapse,  139.  142 

syn.,  anat.,  path.,   339;    etiol.,  symp., 

140;  diag.,  prog.,  treat.,  141 
diff.  fr.  lobar  pneumonia,  120;   fr.  lob- 
ular pneumonia.  125 ;   f r.  pneumonia, 
fr.  pleurisy,  141 
Pulmonary  emphysema,  12,  107-112 

anat.,  path.,   107;    etiol..    symp.,   108; 

diag.,  110;    prog.,  treat.,  112 
diff.    fr.     chronic    bronchitis,    93;     fr. 
asthma,   105;   fr.  pneumothorax,  110: 
fr.  acute  tuberculosis,  fr.  fibroid  dis- 
ease of  the  lungs,  fr.  asthma,  111 
fissures,  8 
gangrene,  144,  145 


Pulmonary  gangrene,  anat.,  path.,  144:  etiol., 
symp.,  diag.,  prog.,  treat.,  145 
diff.  fr.  phthisis,  fr.  bronchitis,  fr.  di- 
latation of  the  bronchial  tubes,  145 
hemorrhage,  134-136 

syn.,  anat.,  path.,   134;    etiol.,  symp., 

diag.,  135;  prog.,  treat.,  136 
diff.  fr.  bronchitis,  93,    94;   fr.   haema- 
temesis,    fr.     epistaxis,    fr.     hemor- 
rhage  from  the  gums  or  the   phar- 
ynx, 135,  136 
hyperaemia,  132-134 

anat.,  path.,  132;   etiol.,  symp.,  prog., 
133;  treat.,  134 
cedema,  30,  142-144 

anat.,  path.,  etiol.,  142;   symp.,  diag., 

prog.,  treat.,  143 
diff.  fr.  capillary  bronchitis,  97,  143;  fr. 
pneumonia,  120.  143;    fr.   pneumonia, 
fr.  hydrothorax.  143 
phthisis,  13,  156-176 

syn.,  156;  prog.,  169;  treat..  170 
diff.  f r.  pleurisy,  69 ;    f r.  bronchitis,  93, 
94;    fr.   capillary  bronchitis,   98;   fr. 
bronchiectasis,    101 :    fr.   pneumonia, 
120 ;  f r.  pulmonary  gangrene,  145 ;  f  r. 
pulmonary  cancer,    147;    fr.  hydatid 
cysts  of  the  lungs,  149 :  f r.  syphilitic 
disease  of  the  lungs,  151 ;  f  r.  enlarged 
bronchial  glands.  153 
resonance,  exaggerated,  28 
semilunar  valves,  178 
thrombosis  and  embolism,  138,  139 

anat.,  path.,  138;   etiol.,  symp.,  diag., 
prog.,  treat..  139 
tuberculosis,  30.  156-165,  169,  170 

anat.,  path..   156;    etiol.,    158;    symp., 
159;  diag.,  164;  prog.,  169, 170;  treat., 
170 
diff.  fr.  other  forms  of  phthisis,  166 
tumors,  148-153 
Pulmonic  obstruction,  regurgitation,  226 
Pulsating  empyema.  77 

diff.  fr.  aortic  aneurism,  263 
Pulsation    in    the  veins   on   the  back  of  the 

hands,  cause  of,  207 
Pulse,  an  indication  of  action  of  the  heart,  185 
normal  radial,  illus.,  208 
senile,  illus.,  210 
Punch  forceps,  485 
Purring  tremor,  187 

Pus,  diff.  fr.  serum  in  the  pleural  sac.  77 
Putrid  or  fetid  bronchitis,  91,  102 
Pyaemia,  diff.  fr.  glanders,  590 
Pyo-pericardium,  217 
Pyo-pneumothorax,  88 
Pyramidal,  pyriform  sinuses,  2% 
Pyrenees,  goitre  in,  629 
Pyriform  sinuses,  diseases  of  the.  393 

Quaes- 's  stethometer,  illus.,  17 
Quality  of  a  murmur,  third  in  importance.  196 
of  sound,  23,  39,  41 ;  of  heart  sounds  modi- 
fied by  disease,  191 
Quinsy,  syn.  of  acute  tonsillitis,  362;    syn.  of 
phlegmonous  tonsillitis,  368 


080 


INDEX. 


Rales  or  rhonclii,  illus.,  48-52 

Ramon  de  la  Sota,  lupus  of  the  larynx,  452 

Rampolla,  retro-nasal  fibrous  tumors,  621 

Rankin,  D.  N.,  myasis  narium,  605 

Rapid  tracheotomy,  425,  426 

Raulin.  rhinitis,  532 

Recessus  pharyngei,  illus.,  300 

Red  hepatization,  118,  114;  illus.,  117 

Reduplication  of  sounds  of  the  heart.  198 

Reference  Handbook  of  the  Medical  Sciences, 

leptotbrix  buccal  is,  376 
Reflected  light  for  laryngoscopy,  275-278 
Reflectors,  laryngeal,  275-283;  perforated  con- 
cave, 283 
Regeneration  of  atrophied  structure,  550 
Regions  of  the  chest,  illus.,  4-8 
Regurgitation,   aortic,   mitral,  tricuspid,  pul- 
monic, 225,  228,  230 
Renal  origin  of  dropsy,  11 

Resection  of  the  ribs  in  pleurisy,  differing 
views.  78-80;  in  abscess  of  the  lung, 
131 ;  of  the  larynx  described,  481 
Resonance,  normal  vesicular,  25;  cracked  pot, 
28,  31;  exaggerated  pulmonary,  28; 
tympanitic,  28,  29;  amphoric,  vesic- 
ulotympanitic, 28,  30;  normal  vocal, 
55,  56 
Respiration,  bronchial,  broncho  -  vesicular, 
laryngeal  and  tracheal,  41 ;  exagger- 
ated, feeble,  42;  suppressed,  inter- 
rupted, or  cog-wheel,  43;  rude, 
broncho- vesicular  or  harsh,  44;  cav- 
ernous, broncho  -  cavernous,  am- 
phoric, 46 
Respiratory  organs,  physiological   action   of, 

38,  39 
Retraction  of  the  lung,  syn.  of  consolidation 

of  the  lung,  237 
Retro-nasal  cartilaginous  tumors,  625 

catarrh,  syn.  of  rhino-pharyngitis,  607 
fibro-mucous  tumors,  illus.,  624,  625 

anat.,   path.,  etiol.,  symp.,  diag.,  624; 

prog.,  treat..  635 
diff.    fr.    fibrous   tumors,    fr.    mucous 
polypi,  fr.  malignant  growths,  624 
fibrous  tumors,  620-624 

anat.,  path.,  etiol.,  symp.,  620;  diag., 

prog.,  treat.,  621 
diff.  fr.  polypi,  fr.  sarcomata,  621 
Retro-pharyngeal  abscess,  383-386 

anat.,  path.,  etiol.,  383;  symp.,  diag., 

384;  prog.,  treat..  385 
diff.  f r.  croup,  fr.  oedema  of  the  glottis, 
fr.  foreign  bodies,  fr.  convulsive  dis- 
orders, 384.  385;  fr.  phlegmonous  lar- 
yngitis, 428;  fr.  abscess  of  the  larynx. 
430 
Revue  d'Hygiene  et  de  Police  sanitaire,  infec- 
tion of  diphtheria.  Grancher.  334 
de  Laryngologie,  d'Otologie  et  de  Rhino- 

ogie.  rhinitis.  Raulin,  532 
mensuelle  des  Maladies  de  PEnfance,  spasm 
of  the  glottis,  Lubet-Barbon,  496;  for- 
eign bodies  in  the  oesophagus,  B.  Po- 
likier,  642 
Rheumatic  pharyngitis  diff.  fr.  diphtheria.  331 


Rheumatic  sore  throat.  316-331 ;  acute,  316,  317; 

chronic,  818  381 
Rheumatism,  diff.  fr.  glanders,  590 

nasal  affections  in,  591 
Rhinitis,  522-552;    simple  acute,  522-526;  acute 
in  infants,traumatic,526;  chronic,  527- 
552;    intumescent,  531-540;   hypertro- 
phic,   540-547;    atrophic,   547-552;   in 
measles,  scarlet  fever.  591 
chronica,  syn.  of   chronic  rhinitis.  527 
hypersesthetica,  syn.  of  hay  fever,  553 
Rhinoliths,  604,  605 

symp.,  604;    diag.,  prog.,  treat.,  605 
diff.  fr.  atrophic  rhinitis,  549;  fr.  nasal 
bony  tumors,  572;  fr.  malignant  tu- 
mors, 573 ;  fr.  osteoma,  f r.  cancer,  605 
Rhino-pharyngitis,  607-610 

syn.,  etiol.,   007;    symp.,   diag.,  prog., 

608;  treat.,  609 
diff.  fr.    adenoid  growths,  fr.  syphilis, 
608 
Rhinoscleroma,  588,  589 

etiol..  diag..  prog.,  treat.,  589 
diff.    fr.   syphilis,   fr.   epithelioma,    fr. 
keloid,  589 
Rhinoscope,  a,  272 

with  uvula  holder,  illus.,  306 
Rhinoscopic  image,  illus.,  307 
Rhinoscopy,  illus.,  272,  293-310;   anterior,  301, 
302;  posterior,  302-306 
obstacles  to  posterior,  304,  305 
Rhonchi  or  rales,  48-52 
Rhonchial  fremitus,  bronchial  or,  16 
Rhythm  of  sounds,  39,  41 ;  of  a  murmur,  second 
in    importance,    196,    200;    of    heart 
sounds  modified  by  disease,  191,  193 
of  the  heart,  illus.,  182,  183 
Ribs,  resection  of  the,  78-80, 131 
Riegel,  signs  of  chronic  myocarditis,  232 
Riehl  (see  Chiari  and  Riehl) 
Right-angle  cutting  forceps,  597 
Rima  glottidjs,  298 

Robinson,  Beverley,  asthma  due  to  poison  in 
the  blood,  104;  feeding  in  laryngitis, 
443;  rhino-pharyngitis,  607,  609 
Roe,  J.  O. ,  hay  fever   related  to  conditions  in 
nasal    passages.  553;    nasal   vascular 
tumors,  570;  fracture  of  the  nose,  594 
Rose  cold,  syn.  of  hay  fever.  553 
Rotch,  T.  M.,  pericarditis.  215 
Rouge,  retro-nasal  fibrous  tumors.  621 
Roux    and    Yersin,   Klebs-Loffler    bacillus  in 
mouths  of  healthy  children,  329,  car- 
bolic or  boric  acid  in  diphtheria,  336 
Rubber  palate  retractor,  illus.,  306 
Rude,  broncho-vesicular  or  harsh  respiration. 

44 
Ruffer.  Armand,  diphtheritic  bacilli.  329 
Rupture  of  the  heart,  syinp.,  245 

Sacculds  laryngis,  the,  297 

Sajous,  Charles  E.,  self-retaining  nasal  specu- 
lum, illus..  301;  simple  membranous 
sore  throat,  326;  cocaine  in  tubercular 
sore  throat,  352:  syphilitic  sore 
throat,  356;  chromic  acid  in  trachoma 


IXDEX. 


681 


of  vocal  cords,  409;  hay  fever  related 
to  conditions  in  nasal  passages,  553 ; 
snare,  567 ;  nasal  osseous  cysts,  570 ; 
knife,  nasal  saws,  illus.,  599 

Salicylic  acid,  objectionable  in  pericarditis, 
216 

Salter,  heredity  in  asthma.  103 

Sands,  cesophagotome,  illus.,  636 

Sansom,  treatment  of  ulcerative  endocarditis, 
233;  diagnosis  of  congenital  diseases 
of  the  heart  in  children,  246 

Sarcomata,  467,  478 

diff.  fr.  nasal  mucous  polypi,  566 

Saws,  nasal,  599 

Scalds  and  burns  of  the  pharynx,  symp. ,  diag. , 
prog.,  treat.,  392 

Scapular  region,  4,  7 

Scarification  of  the  tonsils,  367,  369 

Scarlatina,  diff.  fr.  acute  sore  throat,  312;  fr. 
diphtheria.  332;  fr.  acute  tonsillitis, 
364,  365 

Scarlet  fever,  sore  throat  of,  323,  324;  laryn- 
gitis due  to,  455;  nasal  affections  in, 
591 

Schaffer,  Max,  nasal  papillary  tumors,  569; 
differentiation  of  nasal  affections,  566 

Schech,  anaesthesia  of  the  larynx,  499 

Schiffers,  myxomata  transformed  into  sarco- 
mata, 566 

Schmidt  "s  Jahrbuch,  pleurisy,  Biegauski,  66; 
epilepsy  following  irritation  of  pleu- 
ral surfaces,  De  Cerenville,  78 

Schnell,  Ferdinand,  the  aneurismatoscope,  261 

Schrotter,  head  band  for  reflector  in  laryngo- 
scopy, illus.,  278;  tubes,  dilators. bou- 
gies or  sound,  433,  449,  457,  472,  485,  515 

Schuller,  Max,  tracheotomy,  486 

Schuster,  nasal  syphilis,  576 

Scirrhus  of  the  lungs,  syn.  of  fibroid  phthisis, 
167 

Scissors  for  amputating  the  uvula,  illus.,  359; 
nasal,  545;  heavy  bone.  600 

Scrofulous  eruptions,  diff.  fr.  glanders,  590 
sore  throat,  348-350 

etiol.,    348;   symp.,    diag.,    234;    prog. 

treat.,  350 
diff.  fr.  lupus  of  the  pharynx,  fr.  syph- 
ilis, fr.  tuberculosis,  349;  fr.  acute  tu- 
bercular sore  throat,  352 ;  f  r.  syphilitic 
sore  throat,  355 

S-curve,  illus.,  64 

Sea  voyage  for  convalescents  from  subacute 
pleurisy,  75:  for  plastic  bronchitis, 
100 :  for  hay  fever,  555 

Seashore  for  hay  fever,  456 

Seat  of  a  murmur  first  in  importance,  196 
of  heart  sounds  modified  by  disease.  191,  192 

Second  stage  of  pneumonia,  period  of  red  hepa- 
tization, 117;  of  phthisis,  161,  162;  of 
pericarditis,  213,  214 

Sections  of  head,  illus.,  302,  541,  579,  584 

Sedatives,  formula?,  gargles,  647 ;  trochisci  or 
lozenges.  647;  vapor  inhalations,  650; 
spray  inhalations.  651 ;  dry  inhala- 
tions, 654:  fuming  inhalations,  655; 
insufflations,  656 


Seiler,  Carl,  tube  forceps,  illus.,  495 
Self -retaining  nasal  speculum,  301 
Senile  pulse,  illus..  210 

Senn,  Nicholas,  guaiacol  in  phthisis,  173;  lar- 
yngoscopy, 272 
Septic  endocarditis,  syn.  of  acute  endocarditis, 

219 
Septum  forceps,  knife,  600 
Septum  narium,  illus.,  308 
abscesses  of  the  nasal,  603 
deflection  of  the  nasal,  594-597 
ecchondroma  and  exostosis  of   the   nasal, 

597-601 
hasmatoma  of  the  nasal,  602 
perforation  of  the  nasal,  601,  602 
Sero-fibrinous  pleurisy,  61 
Serum  diff.  fr.  pus  in  the  pleural  sac.  77 
Sex   modifies   form   of   chest   and  percussion 

sounds,  10,  11,  27 
Shattuck   cites   Soltmann   on   asthma   among 

Hebrews,  103 
Shawl-pin  removed  from  the  trachea,  a,  495 
Shoemaker,  pilocarpine  for  erysipelas,  429 
Short  f rasnulum  obstacle  to  laryngoscopy,  290 
Shortened  inspiration,  43 

Shurly,  E.  L.,  battery,  345;  iodine  hypodenni- 
cally    for    immunity    to    tubercular 
virus,  172,  442 
Sibilant  rales,  48,  49 
Sibson.  treatment  of  endocarditis,  221 
Signs  and  symptoms  differentiated,  9 
of  inter-thoracic  disease,  16 
tussive.  59 
nervous,  206 
Simon,  capillary  bronchitis  in  children,  98 
Simple  acute  rhinitis.  522-526 

syn.,  anat.,  path.,  etiol.,  522:    symp., 

523;  diag.,  prog.,  treat.,  524 
diff.  fr.  hay  fever,  524,  554;  fr.  inflam- 
mation of  the  antrum  or  frontal  si- 
nuses, fr.  measles,  524 
acute  sore  throat  diff.  fr.  acute  follicular 

pharyngitis,  339 
cardiac  hypertrophy.  234-236 

syn.,  etiol.,  symp.,  234;   diag.,  prog., 
235;  treat.,  236 
catarrhal  inflammation  diff.    fr.  syphilitic 

sore  throat  in  infants.  357 
chronic  rhinitis,  528-530 

etiol.,    symp.,   528;    diag.,  prog.,  529; 

treat.,  530 
diff.  f r.  hay  fever,  529 ;  f r.  intumescent 
rhinitis.  534 
membranous  sore  throat.  324-327 

syn..  anat.,  path.,  324;    etiol..  symp., 

325;  diag.,  prog.,  treat.,  326 
diff.  fr.  diphtheria.  326,  332;   fr.  syphi- 
litic sore  throat,  355 
Sinus,   empyema  of  the  frontal,  581 ;    of  the 
sphenoidal,  583.  584 
inflammation  of  the  frontal.  584,  585 
Sinuses,  diseases  of  the    valeculae  and  pyri- 
form.  393 
of  Valsalva,  aneurism  o    the   257,  259 
pyramidal,  pyriform.  laryngopharyngeal, 
296 


682 


INDEX. 


Siphon  drainage  in  pleurisy,  79.  82 

Skoda,  bronchial  sound.  46;  heart  sounds,  100 

Small-pox,  sore  throat  of.  381,  322;    laryngitis 

due  to,  455 ;  nasal  affections  in,  591 
Smeleder,  support  of  reflector  in  laryngoscopy, 

277 
Smith  and  Warner,  pseudo-diphtheria,  329 
Smoker's  patches  d iff.  fr.  leucoplakia  buccalis, 

361 
Snare  for  excisions  in  the  throat,  386,  507,  570 
applicator,  post-nasal,  623 
forceps,  473 
Sodium  sulpho-carbolate  in  endocarditis,  223 
Solid  mediastinal  tumors.  207.  268 

syrnp.,  267;  diag. ,  prog.,  treat.,  268 
diff.  fr.  thoracic  aneurism.  262 
Soltmann.  asthma  among  Hebrews,  103 
Sonorous  rales,  48 

Sore  throat,  acute,  311-314;  erysipetalous,  314- 
810;  rheumatic,  310-321 :  acute  rheu- 
matic. 316,  317;  chronic  rheumatic. 
318-321 ;  simple  membranous.  324-327  ; 
scrofulous,  348-350;  acute  tubercular, 
350-353;  syphilitic,  353-357 
throat    of    measles,    symp.,  diag.,    prog., 

treat..  322 
throat  of  scarlet  fever.  323.  324 

anat.,  path.,  symp.,  diag.,  323;    prog., 
treat.,  324 
throat  of  small-pox.  821,  322 

anat..  path.,  diag.,  prog.,  treat..  322 
Sound  in  moving  fluid   transmitted  in  the  di- 
rection of  motion.  19! 
South  America,  myasis  nariuiii.  005 
South  Carolina  for  phthisis,  175 
Spain  for  phthisis,  175 
Sparteine  in  chronic  endocarditis,  229 
Spasm  of  the  adductors  diff.  fr.  paralysis  of 
the  abductors.  513 
of  the  glottis,  490.  497 

syn..  symp.,  diag. ,496;  prog.,  treat..  497 
diff.  fr.  acute  laryngitis,  395.  390:    fr. 
phlegmonous  laryngitis.  427;  fr.  true 
croup.  414.   197 
of  the  larynx  in  adults.  497,  498 

etiol..  497;  symp.,  diag.,  prog.,  treat.. 

498 
diff.  fr.  asthma,  105 
of  the  oesophagus.  63! 

syn..  etiol..  symp.,  637;    diag.,  prog., 

treat.,  638 
diff.    fr.    stricture  of  the  oesophagus, 
635;  fr.  paralysis,  639 
of  the  pharynx,  etiol. ,  symp. ,  diag. ,  prog. , 
treat.,  390 
diff.  fr.  stricture  of  the  oesophagus,  fr. 
paralysis,  fr.  paralysis   of   the  pha- 
rynx or  the  oesophagus.  390 
of  the  vocal  cords.  502.  503 

anat.,  path.,  502;  symp..  treat..  503 
Spasmodic  asthma  diff.  fr.  hay  fever.  .V>4 
stricture  of  the  oesophagus,  syn.  of  spasm 

of  the  oesophagus.  037 
croup,  syn.  of  spasm  ol  the  glottis.  496 
Spasmus  glottidis,  syn.  of  spasm  of  the  glot- 
tis, 496 


Spatula,  nasal.  600 

Sphenoidal    sinuses,    empyema    of     th>'. 
584 

Sphygmograph,  the,  illus. ,  808-211,  260 

Spirometer,  illus.,  18 

Spleen,  variable  in  size,  27;  enlargement  of, 
diff.  fr.  pleurisy,  70 

Spray  inhalations,  formula?.  651-653 

Sprays,  powders,  pigments,  of  successive  value 
for  chronic  laryngitis.  405 

Spud,  nasal,  599 

Staining  tubercular  bacilli,  164,  166 

Staphylococci  in  pleurisy,  01 

Starvation  treatment  of  aortic  aneurism.  206 

Stenosis  of  the  aorta,  syn.   of  coarctation  of 
the  aorta,  366 
of  heart  valves  produced.  224.  228 
of  the  larynx,  chronic,  456-459 
of  the  trachea,  diag..  prog.,  treat..  400 

Sterilized  air  in  pneumothorax,  88 

Sternal  region,  4,  6,  7 

Sternberg,  diplococcus  pneumonia?.  115 

Stethogoniometer.  18 

Stethometer.  17 

Stethoscopes.  34-37;  disadvantages  of.  34 

Stimulant  and  caustic  pigments.  656  (see 
astringents  and  stimulants,  antisep- 
tics and  stimulants) 

Stimulants,  formula?,  gargles,  647:  trochisci 
or  lozenges.  643:  vapor  inhalations, 
650,  651 ;  dry  inhalations.  654 

Stimulating  injections  for  pleurisy,  81 

Stirling,  inhalation  of  lime  water  in  plastic 
bronchitis.  100 

Stoerk,  ecraseur.  guillotines,  forceps,  blades, 
illus..  473 

Stokes,  pseudo-apoplexy  and  fatty  heart,  244 

Stowell,  C.  H.,  sections  of  head,  illus..  302, 
541,  579,  584 

Streptococci  in  pleurisy,  61 

Streptococcus  erysipelatosus.  315 

Strickler.  W.  M.,  resection  of  ribs  for  pleu- 
risy, 78 

Stricture  of  the  resophagus,  634.  637 

anat..  path.,  etiol.,  symp.,  634;    diag., 

prog..  635;  treat.,  630 
diff.  fr.  spasm  of  the  larynx,  390;  fr. 
tubercular  laryngitis,  fr.  tumors  in 
the  pharynx,  larynx,  oesophagus,  fr. 
spasm,  fr.  paralysis,  fr.  foreign 
bodies,  fr.  spasm,  635 

Strong,  A.  B.,  resection  of  ribs  for  pleurisy, 
78;  drainage  tubes,  illus.,  79 

Strophanthus  in  exopthalmic  goitre.  632 

Struma,  syn.  of  goitre,  629 

Subacute  bronchitis  (see  acute  bronch  i t i s"> 
laryngitis,  397,  398 

prog.,  treat.,  397 
pericarditis,  212 
pleurisy,  12,  72-75 

anat..  path.,  etiol.,  72:    symp.,  diag., 
prog.,  treat.,  73 

Subclavian  murmurs,  306 

Subcrepitant  rales.  4^  50 

Subcutaneous  emphysema  shown.  11 

Subglottic  hypertrophy.  401 


INDEX. 


683 


Submucous    infiltration    of   the   sides   of   the 
vomer,  illus. ,  diag. ,  treat.,  547 
laryngitis,  syn.  of  phlegmonous  laryngitis, 

427 
laryngitis,  syn.  of  oedema  of  the  larynx, 
430 
Succussion,  9,  20,  86 

Suffocative  laryngismus,  syn.  of  spasm  of  the 
glottis,  496 
stage  of  croup.  412 
Superficial  ulceration  in  syphilitic  sore  throat, 
353;  of  vocal  cords,  of  epiglottis,  il- 
lus., 395 
Superior  costal  breathing,  11 
meatus,  illus.,  309 
sternal  region,  4,  6 
turbinated  bodies,  illus.,  309 
Suppressed  respiration,  43 
Suppuration  of  the  anterior  ethmoid  cells  diff. 
fr.  empyema  of  the  antrum,  581 
of  the  antrum,  diff.  fr.  atrophic  rhinitis, 
549;    fr.  chronic  suppurative  ethmoi- 
ditis,  586 
Suppurative  ethemoidltis,  chronic,  585-587 
tonsillitis,  syn.  of  phlegmonous  tonsillitis, 
368 
Supra-arytenoid  cartilages,  296 
Supra-clavicular  region,  4 
Supra-glottic  dropsy,  syn.   of  oedema  of  the 

larynx,  430 
Supra-scapular  region,  4,  7 
Supra-sternal  region,  4,  6 
Supra-thyroid  laryngotomy,  475 
Swallowing  the  tongue,  392,  393 

treat.,  393 
Swiss  mountains  for  phthisis,  175;    goitre  in, 

629 
Symonds,  Charters  J. ,  gum-elastic  tube  to  keep 
stricture  of  oesophagus  pervious,  636 
Symptoms  and  signs  differentiated,  9 
Syphilis  of  the  nose,  574-577 

anat. ,  path.,  etiol.,  574;    diag.,  prog., 

treat.,  575 
diff.  fr.  atrophic  rhinitis,  549,  575;  fr. 
simple  catarrhal  rhinitis,  fr.  lupus, 
575 ;  f  r.  empyema  of  the  antrum,  581 ; 
fr.  lupus  of  the  nares,  588;  fr.  rhi- 
noscleroma,  589;  fr.  glanders,  590; 
fr.  rhino-pharyngitis,  608 
of  the  trachea,  illus. ,  487,  488 

anat.,  path.,  etiol.,  symp.,  487;   diag., 
prog.,  treat.,  488 
Syphilitic  condylomata  of  the  larynx  diff.  fr. 
benign  growths,  468 
disease  of  the  heart,  245 
disease  of  the  lungs,  151,  152 

symp. ,  diag. ,  151 ;   prog. ,  treat. ,  152 
laryngitis,  illus.,  443,450,  456 

etiol.,  symp.,  444;    diag.,  446;    prog., 

treat.,  448 
diff.  fr.  chronic  laryngitis,  403;  fr. 
tubercular  laryngitis,  439,  440;  fr. 
tubercular  laryngitis,  fr.  tumors, 
446-448;  fr.  lupus,  453;  fr.  benign 
tumors  of  the  larynx,  468 ;  fr.  cancer, 
479 


Syphilitic  laryngitis  in  infants,  449,  450 
diag.,  449;  prog.,  treat.,  450 
patches  diff.  fr.  leukoplakia  buccal  is,  362 
sore  throat,  illus.,  353-357 

anat.,  path.,  353;    etiol.,  symp.,  diag., 

354;  prog.,  treat.,  355 
diff.  fr.  chronic  rheumatic  sore  throat, 
320;  fr.  chronic  follicular  pharyn- 
gitis, 344;  fr.  scrofulous  sore  throat, 
349;  fr.  catarrhal  sore  throat,  fr. 
scrofulous  sore  throat,  fr.  tubercular 
sore  throat,  354,  355 ;  f r.  acute  tonsil- 
litis, 366;  fr.  cancer  of  the  pharynx, 
387 
sore  throat  in  infants,  356,  357 

anat.,  path.,  etiol.,  diag.,  prog.,  treat., 

357 
diff.  fr.  simple  catarrhal  inflammation, 
357 
ulceration  of  the  tonsil  diff.  fr.  tubercular 
ulceration  of  the  tonsils,  378;  fr.  can- 
cer, 380,  381 
Syringe,    nasal,   550;    hypodermic,   568;    post- 
nasal, 609 
Systole  of  the  heart,  180;  auricular,  illus.,  201; 

ventricular,  illus.,  202 
Systolic  murmur,  201,  202 
souffle,  244 
venous  pulsation,  cause  of,  207 

Tachycardia,  249 

prog.,  treat.,  249 
Taenia  echinoc,  coccus,  cause  of  hydatid  cysts 

of  the  lungs,  148 
Tait's  Cliniques  de  Laryngotomie,  thyrotomy, 

Krishaber,  475 
Tampon,   for  the  nose,  wool,  552;    surgeons' 
lint,  561,  562;  lint  or  gauze,  600;  styp- 
tic gauze,  624 
Teeth,  empyema  of  the  antrum  from  diseased, 

579 
Tennessee  mountains  for  phthisis,  175 
Texas  for  phthisis,  western,  175 
Thickening  of  turbinated  bodies  diff.  fr.  mu- 
cous polypi,  565 
Third  stage  of  pneumonia,  period  of  gray  he- 
patization, 117;    of  phthisis,  161-164; 
of  pericarditis,  213,  215 
Thompson,  R.   E.,  percussion  sounds,  28,  30; 

pulmonary  emphysema,  110 
Thoracic  aneurism,  aortic  or,  256-266 

arteries,  diseases  of  the,  254-268 
Three  stages  of  acute  pleurisy,  81 ;    of  pneu- 
monia, 117;  of  phthisis,  161;  of  peri- 
carditis, 213 ;  of  croup,  412 
Throat,  the,  271-310 

acute  rheumatic  sore,  316-317 

acute  sore,  311-314 

acute  tubercular  sore,  350-353 

chronic  rheumatic  sore,  318-321 

consumption,  syn.  of  tubercular  laryngitis, 

434 
deafness,  610-613 

etiol..    symp.,   610;    diag.,  prog.,   611; 
treat.,  612 
diseases  of  the,  271-515 


684 


INDEX. 


Throat,  erysipelatous  sore.  314-316 
gout3-  affections  of  the.  319 
mirrors  for  laryngoscopy,  illus.,  273 
of  measles,  sore.  332 
of  scarlet  fever,  sore.  323,  324 
of  small-pox.  sore.  321,  322 
rheumatic  sore,  316-321 
scrofulous  sore,  348-350 
simple  membranous  sore.  324-3-07 
syphilitic  sore.  353-357 
Thrombosis  and  embolism,  pulmonary,  138,  139 
Thymus    vulgaris,  unsatisfactory  with  pertus- 
sis, 155 
Thyro-arytenoid    muscles,    paralysis    of    the. 

507.  508 
Thyro-epiglottic   and    ary-epiglotcic  muscles, 

paralysis  of,  505 
Thyroid  gland,  diseases  of  the.  629-632 
Thyrotomy  described.  474-47(3.  483 
Tink'.ing,  metallic.  20.  54.  87,  -s 
Tobacco  smoking  a  cause  of  leukoplakia  buc- 
calis.  360 
sore   throat,    diff.    fr.    chronic    rheumatic 
sore  throat.  320 
Tobold.  illuminator.  280;  laryngeal  knives,  il- 
lus.. 474 
Tongue,  arching  of  the.  200:    swallowing-  the. 
392;    enlarged   glands   and   veins   at 
base  of  the.  319  (see  paresthesia  of 
the  pharynx) ;  depressors,  illus..  271, 
4C4 
Tonsil  forceps,  373 
Tonsilla  pharyngea.  310 
Tonsillitis,   acute.  362-367;    phlegmonous 

369:  chroDic  (see  hypertrophy  of  the 
tonsil) 
Tonsillitome.  the.  372.  373 
Tonsillotomy,  373.  374 
Tonsils,  concretions  in  the.  375 
cancer  of  the.  380,  381 
hypertrophy  of  the,  369-375 
to  generative  organs,  relation  of  the.  375 
hypertrophy  of  the  pharyngeal.  613-620 
Luschka's.  613 
mycosis  of  the.  376,  377 
obstacle  to  laryngoscopy,  enlarged,  290 
removal  of  the.  371-375 
tubercular  ulceration  of  th(       "  S     - 
Tornwaldt.    Dasal     tuberculosis,    571-:    rhino- 
pharyngitis. 607 
Trachea,  examination  of  the.  300 
involution  of  the.  485,  486 

.osis  of  the, 
syphilis  of  the.  487.  488 

il  cartilages,  illti- 
respiration,  laryngeal  and.  41 
tumors,  illus..  4*3.  484 

etiol.,  symp..  diag..  prog.,  treat..  4*4 
Tracheitis.  460-462 

anat..  path.,  etiol.,  symp.,  4C0;    diag.. 

prog.,  treat.,  4^1 
diff.  fr.  laryngitis,  fr.  bronchitis.  4C1 
Tracheocele.  481 

syn..   anat.,  path.,   etiol..   symp.,   486; 
diag..  prog.,  treat..  4  "-7 
Tracheophony,  54 


Tracheotomy  described,  421-426 
in  aneurism  of  the  aorta.  266 
in  various  throat  diseases.  338.  397,  432,  434, 
442,  448,  450,  454,  455,  457.  459,  470.  472. 
474,  481.  484,  486,  488,  495 
rapid.  425.  426 
vegetations  after,  485 
Trachoma  of  the  vocal  cords,  illus.,  408,  409 

syn.,  anat..  path.,  etiol..  symp.,  diag., 
prog.,  treat.,  408 
Transillumination  of  the  antrum.  580;  electric 

lamp  for.  581 
Traube,  pulmonary  percussion,  66 
Traumatic    laryngitis,    symp..    diag.,    prog., 
tivat..  398 
rhinitis.  526.  527 

symp.,  treat..  527 
Traveller's  nasal  douche,  illus.,  551 
Trephines,  nasal.  546 
Triangle  of  dulness.  illus.,  64 
Tricuspid  area,  illus.,  198,  199 
obstruction.  226.  228 
regurgitation.  225.  228,  230 
stenosis.  225.  228 
valves.  7,  178 
Trocar,  flat.  79 

Trochisci  or  lozenges,  formula?.  647-649 
Trousseau,  percussion.  32:  laryngoscopy,   272; 

tracheal  forceps.  495 
True  croup,  syn.  of  membranous  croup,  411 
Tube  for  antrum,  drainage.  583 
forceps.  472 

to  keep  stricture  of  oesophagus  pervious,  636 
Tubes  for  chronic  pleurisy,  drainage,  79-83 

for  intubation.  418 
Tubercle  bacilli,    illus.  ,157;   staining,  164;   in 
lupus  of  the  larynx,  451 
bacillus.  Koch.  159 
Tubercles,  mucous,  353 
Tubercular  laryngitis,  illus.,  434  443 

syn.,  434;  anat..  path.,  435:  etiol., 
symp.,  436:  diag..  437:  prog.,  treat., 
431 
diff.  fr.  chronic  laryngitis.  403:  fr. 
anaemia,  fr.  (edema  of  the  larynx,  fr. 
catarrhal  laryngitis,  fr.  syphilis. 
437-440;  fr.  syphilitic  laryngitis.  447; 
fr.  lupus,  452:  fr.  benign  tumors,  468; 
fr.  cancer.  479 
sore    throat    (see    acute    tubercular    sore 

throat) 
ulceration  of  the  tonsils.  378-380 

anat..  path.,  symp.,  diag..  378:    prog., 

379;  treat..  380 
diff.  fr.  syphilis,  fr.  cancer.  379 
Tuberculin  of  doubtful  value  in  phthisis,  173; 
disastrous    results    in    lupus   of    the 
larynx.    453:    in   tuberculosis   of   the 
nares,  579;  curative  in  lupus   of   the 
nares.  588;     inactive    in   rhinosclero- 
ma.  589 
Tuberculosis  (see  acute  tubercular  sore  throat) 
acute  miliary.  165-167 
of  the  nares,  578,  579 

anat..    path.,     etiol..     symp..     diag., 
prog.,  treat 


INDEX. 


G85 


Tuberculosis  of  the  nares  cliff,  fr.  lupus  of  the 
nares,  588 
pulmonary,  156-165 
Tufnell,  treatment  of  thoracic  aneurism,  266 
Tumors,  see  also  aneurism 

nasal:    fibrous,    569;    papillary,   569,    570; 
vascular,     570;      cartilaginous,    571; 
bony,  571,  572;  malignant,  572,  573 
of  the  heart,  diag. ,  prog.,  treat.,  246 
of  the  larynx:    benign,  465-476;    cartilagi- 
nous, 468;  malignant,  476-483 
of  the  naso-pharynx :  malignant,  625;  cys- 
tic, 626 
of  the  pharynx,  illus. ,  treat.,  386 
pulmonary,  148-153 
retro-nasal,  fibrous,  620-624;  fibro-mucous, 

624;  cartilaginous,  625 
solid  mediastinal,  193,  267,  268 
tracheal,  483,  484 
Turbinated  bodies,  308;  hypertrophy  of,  541,  542 
Tiirck,  tongue  depressor,  illus.,  271;    laryngo- 
scopy, 272 ;  attempt  to  magnify  laryn- 
geal image,  282;  syphilitic  laryngitis, 
446 
Turgescence,  venous,  206,  262,  267 
Tussive  signs,  59 

Tympanitic  resonance,  26,  28,  29,  30,  66 
Typhoid  fever,  nasal  affections   in,  591 ;    diff. 
fr.  pneumonia,  121 ;  fr.  glanders,  590 
pneumonia,  128 

Ulceration  of  the  pharynx,  357 

of   the  tonsils:    tubercular,   378-380; 
syphilitic,  379,  381 
Ulcerative  endocarditis,  222,  223 

etiol.,  symp.,  diag..  prog.,  222,  treat., 
223 
Unilateral  paralysis  of  the  lateral  crico-aryte- 
noid  muscles,  illus.,  510,  511 
etiol.,  symp.,  diag.,  510;  treat.,  511 
paralysis  of  the  posterior  crico-arytenoid 
muscles,  illus.,  symp.,  diag.,  prog., 
treat.,  514 
Unilocular  pleurisy  diff.  fr.  other  forms,  83 
United  States,  goitre  in,  629 
Utah  for  phthisis,  175 
Uvula,  abscission  of  the,  359 

acute  inflammation  and  oedema  of  the,  358 

and  palate  retractor,  self -retaining,  306 

diseases  of  the,  358-300 

elongated,  289,  305,  343 

chronic   inflammation   and    elongation  of 

the,  358,  359 
malformations  and  new  growths  of  the,  359, 

360 
malignant  growths  in  the,  360 
Uvulatome  scissors,  illus.  „  359 

VALECULiE,  the,  illus.,  295 

and  pyriform  sinuses,  diseases  of  the,  393 
Valsalva,    sinuses  of,   257,   259;    treatment  of 

aortic  aneurism,  266 
Valves  of  the  heart,  7,  178 ;  position  of  the,  179 
Valvular  disease  of  the  heart  (see  chronic  en- 
docarditis) 
murmurs,  203 


Vapor  inhalations,  formulae,  649-651 

Vaporizer,  612 

Vapors  from  lime  water  in  membranous  croup,' 

416 
Varicose  veins  at  base  of  tongue,  389 

diff.  fr.  chronic  rheumatic  sore  throat, 
319 
Vascular  tumors,  angiomata  or,  467 

tumors,  nasal,  570 
Vault  of  the  pharynx  and  posterior  nasal  cavi- 
ties, 307-310 
Vegetations,  post-tracheotomy,  485 
Veins  at  base  of  tongue,  varicose,  319,  389 
Velum  palati  attacked  in  syphilitic  sore  throat, 

353,  354 
Venous  murmur  or  hum,  207 

pulsation,  presystolic,  systolic,  206,  207 
signs,  206-208 
Ventilation  with  diphtheria,  mode  of,  334 
Ventricle  of  Morgagni,  eversion  of  the,  483 
Ventricles  of  the  heart,  right  and  left,  178 

of  the  larynx,  the,  297 
Ventricular  bands,  illus. ,  297 
murmurs,  204 
systole,  182;  illus.,  202 
Verneuil,  oesophageal  dilator,  638 
Vertigo,  laryngeal,  504 
Vesicular  emphysema,  107 

murmur,  the  standard  of  comparison,  39, 

40 
resonance,  normal,  25 
Vesiculotympanitic  resonance,  30 
Vierteljahresschrift    fur     Dermatologie    und 
Syphilis,  lupus  of  the  larynx,  Chiari 
and   Riehl,    451 ;    nasal  syphilis  and 
lupus  of  the  larynx,  Shuster,  576 
Virchow,  pulmonary  emphysema,  107;   malig- 
nant endocarditis,  219 
Virchow's    Archiv,    nasal    papillary    tumors, 

Hopmann,  569 
Virginia  mountains  for  phthisis,  175 
Vocal  cords,  illus.,  297 

cords,  atrophy  of  the,  515 
cords,  paralysis  affecting  the,  505-514 
cords,  spasm  of  the,  502.  503 
cords,  trachoma  of  the,  408,  409 
cords,  tumors  of  the,  465-468 
cords,  ulcers  of  the,  395 
fremitus,  normal,  15,  16 
resonance,    normal,    diminished,    55;     in- 
creased or  exaggerated,  56;  whisper- 
ing, 58 
sounds,  54-59 
Voltolini,   attempt  to  magnify  laryngeal  im- 
age, 282;  staff  for  lifting  the  epiglot- 
tis, 291 ;  friction  in  laryngeal  tumors, 
472 ;  transillumination  of  the  antrum, 
580 
Vomer  or  septum,  illus.,  307;  submucous  infil- 
tration of  the  sides  of  the,  illus.,  547 
Von  Stoffella,  pericarditis,  214 
Vulsella  forceps,  367 

Wagner,  Clinton,  pneumonia  contagious,  116; 

retro-nasal  cystic  tumors,  626 
Walsham,  deflection  of  the  nasal  septum,  596 


686 


INDEX. 


Warden,  laryngoscopy,  272 

Warner  Csee  Smith  and  Warner) 

Wash  bottle,  586 

Waxham,  gag,  illus.,  419 

Weber,  cause  of  asthma,  103 

Weber-Liel,  throat  deafness,  610 

Weichselbaum,  diplococcus  pneumonias,  115 

Weill,  carbon  dioxide  in  asthma,  106 
laryngeal  illumination,  280 

Wells,  pneumonia  contagious,  116 

Weitheim,  attempt  to  magnify  laryngeal  im- 
age. 282 

Whisper,  normal  bronchial,  exaggerated,  ca- 
vernous, amphoric,  58 

Whispering  bronchophony,  pectoriloquy,  vocal 
resonance.  58 

Whistler,  cutting  dilator,  illus.,  458 

White  Mountains  for  hay  fever,  555 

Whittaker,  James  T. ,  transmission  of  bacilli  to 
foetus,  158 

Whooping  cough,  pertussis  or,  153-155 

Wiener  medizinische  Presse,  cause  of  putrid 
bronchitis,  Josef  Lumniczer,  91; 
pericarditis,  E.  Pins,  214 

Williams.  C.  J.  D.,  rhinitis,  525 

Winter  cough,  91 

Wintrich,  tympanitic  resonance.  66;  pleurisy, 
83 ;  cause  of  asthma,  103  • 


Woakes,   Edward,  mucous  polypi,  564;  throat 

deafness,  610 
WTolff,  pneumonia  contagious,  115 
Wool  tampons,  552 

Wright,  C.  H.,  burr  for  nasal  surgery,  598 
Wrdblewski,  adenoid  growths  in  deaf  mutes, 

614 
Wyoming  for  phthisis,  175 

Yellow  hepatization,  113,  114 
Yeo,  J.  Burney,  pleurisy  of  the  apex  and  low- 
necked  dresses,  82 
Yersin  (see  Roux  and  Yersin) 

Zejtschrift  der  Bakterienkunde,   contagious 
pneumonia,  Wolff,  115 
fiir   klinische    Medicin,    signs   of   chronic 
myocarditis,  Riegel,  232 

Ziehl,  solution  for  staining  bacilli,  164 

Ziemssen,  chorea  laryngis,  501 

Ziemssen's  Cyclopedia  of  Medicine,  carbolic 
acid  in  diphtheria,  Oertel,  336;  glan- 
ders eleven  years,  Bollinger,  590 

Zimmermann,  siphon  drainage  in  pleurisy,  79 

Zuckerkandl.  nasal  papillary  tumors,  569;  de- 
flector of  the  nasal  septum.  594 

Zwillinger,  H.,  nasal  osseous  cysts,  570 


COLUMBIA   UNIVERSITY 


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